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5AN JUAQUiN LOCAL HEAL T H UIS NIC 1 <br /> FFICE USE: 1601 E. Hazelton- Ave:,,- Stockton; CA 95205 Permit No. -7 <br /> Telephone: (209) .466-6781 <br /> Date Issued 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT __ 1 <br /> _ This Permit -Expires 1 Year From Date Issued <br /> ► Complete In Triplicate <br /> Application is hereby made ;to the San Joaquin Local, Health District for a permit to construct <br /> and/or install -the work her'e'in described. 'This application is made in compliance with San <br /> Loaqu,in County Ordinance NO 1862 and the -Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> t EXACT STREET ADDRESS_ 297 E. -liberty rd . .fie ogmi EBrgA7 3 ACITY/TOWN <br /> Owner's Name Ed ErjLcson Phone <br /> Address i .- 'City <br /> Contractor's Name Mother' Lode Drilling License# 11189 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> ITYPE- OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL:[CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 � <br /> PUM MINSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT [1 <br /> DISTANCE TO NEAREST: SEPTIC TANK nibne SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ` PROPERTY LINE -. PRIVATE DOMESTIC WELL --'PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation / 'g xxv <br /> Domestic/private Drilled Dia. of Well Casing 811y <br /> Domestic/public Driven - Gauge of Casing_ �_f6o psi pvc <br /> Irrigation Gravel Pack Depth of Grout Seal 01 <br /> Cathodic Protection x Rotary Type of Grout 2, to 1 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: d 4 0e5v- <br /> JPUMP INSTALLATION: Contractor <br /> Type'!'of Pump H.P. <br /> ' PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> [ DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Descr*ibe Material and Procedure <br /> i . <br /> I hereby certify. that I have�'.prepared this application and that the work will be done in accordane <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> !Health District. Home owner or licensed agent's signature certifies the following: <br /> ' "I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> ! I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> !SIGNED TITLE: ad-¢-�, DATE: 5- 3"7 <br /> i DRAW PLOT PUN ON REVERSE SIDE <br /> �. FOR DEPARTMENT USE ONLY �!� <br /> `PHASE I <br /> -APPLICATION ACCEPTED .BY DATE S a3 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYE DATE <br /> kEH 1426 Rev_ 12-77. _. 1 /7R 2M <br />