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K. ... - ...,....6.. .� <br /> SAN JOAQUIN. LOCA1_ HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton. Ave. , Stockton, CA 95205. Permit No. ",7 <br /> I Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued��//-7� _ <br /> Tihi.s Permit Ex ires,. l Year From Date Issued <br /> Complete In Triplicate <br /> lApplica-tion is hereby made to the San Joaquin Local .Health District fora ermit to construct <br /> { and/or .install the work herein described. This appliication is made in compliance with San <br /> ,caquin County Ordinance No.t 1862 and the Rules and Regulations of the ,San Joaquin Local Health <br /> tJistr'ct. <br /> F_ EXACT .STREET ADDRESS CITY/TOWN <br /> Phone <br /> 1Owner's Name c <br /> Address r� city <br /> Contractor's Name i _._ 1-icense Phonel <br /> IS CERTIFICATE OF WORKMAN'S C0f.':PENSAT101 INSURA"10E OP1 FILE WITH SJLHD? YES NO <br /> 1TYPE OF WORK (Check,),,: NEW,WELL DQ , .s DEEPEN ❑ RECONDITION ❑ " DESTRUCTION❑ <br /> WELL`!�CHLORINAT'I-ON-0—WELL ABANDONMENT. 0. ' OTHER ❑ Q4 <br /> "PUMP INSTALLATION.,[ °�� PUMP REPAIR REPLACEMENT Q .� <br /> DISTANCE -TO NEAREST: SEPTIC TANK S P SEWER LINES PIT__,-P.RI.VY <br /> ' SEWAGE DISPOSAL = CESSPOOL/SEEPAGE PIT: I. <br /> w� _ :S-O OTHER <br /> PROPERTY LIN-E. -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC ,WELL <br /> INTENDED USE TYPE- OF ;WELL.. - CONSTRUCTION SPECIFICATIONS <br /> Industrial - - Cabl"esTool ,Dia. of Well Excavation <br /> _:� ; Domestic/.prDrilled Di-a. c <br /> ivate � ii f Well Ga=s-ing <br /> Domestic/public Dr` ,ven Gauge. Of Casing � <br /> Y =I rri gati onl Gr <br /> a`vel Pack Depth of Grout' Sy <br /> Cathodic Pratectlon Rot.a`ry Type of Grout .. _ <br /> - Disposal t Other Other Information._ , L <br /> Geophysical Surface Seal Insta-1ti.:;ed: b <br /> PUMP INSTALLATION: Contractor >; ,a <br /> Type of Pump H.P. <br /> ! PUMP REPLACEMENT: n Stfate Work Done <br /> 4 FI <br /> State <br /> REPAIR: ❑State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate DeP <br /> Describe Materia an Procedure <br /> I, hereby certify that I have prepared this application and that the work will be. done in accordance <br /> 'wi.th 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 /> flnot employ any person in :such manner as to become subject to Workman's Compensation <br /> Maws of California." J <br /> I WILL CALL- FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: �1 ' <br /> RAW PLOT PLN ON-. REVERSE SIDE <br /> FOR DEPARTM,RNT USE ONLY <br /> , PHASE I, . <br /> `APPLICATION-.ACCEPTED BY G' d3• A DATE <br /> ADDITIONAL COMMENTS : � . <br /> PHASE .II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ;INSPECTION BY DATE INSPECTION BY e- DATE <br /> k <br /> ,FH 1 A9A Rau 19-77 1 1-74 I)m <br />