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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOg FFiCE USE: 1601 E, Hazelton Ave. , Stockton, CA 95205 Permit No-7 ,/ a <br /> Telephoner (209) 466-6781 Date Issued,5- - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (,Complete In Triplicate) <br /> .<. <br /> Application is hereby made tothe San Joaquin Local Health District for a,permit to construct <br /> and/or ..install the work hereinldescribed. This application is made <br /> tincompliance with aHealth <br /> Joaquin County Ordinance No. 1862 and the Rules andRegulations <br /> District. <br /> CITY/TOWN <br /> ADDRESS 0 I `� <br /> EXACT -STREET �► r Phone 3�g--1' -�•� ' <br /> Owner's Name <br /> Ci ty. <br /> AdJress. <br /> Name •e— Li cense# G �3 73 Phone 3 C �— 3 <br /> Contractor's t. <br /> S CERTIFICATE OF WORKMAN'S COIMP£NSATIOM INSURAINC ON FILE WITH SJLHD? YES <br /> 'T 0 <br /> TYPE OF WORK (Check) : NEW WELL O DEEPEN 0 RECONDITION DESTRUCTION d .WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION ER PUMP REPAIR O PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES .. PIT PRIVY <br /> SEWAGE:DISPOSAL :FIELDS`CESS.P�_O.L/_S.EEPAGE! IT;r-- --- OTHER--� -- _- <br /> —PROPERTY'LI'N'E --PRIVATE DOMESTIC WELL.- <br /> CONSTRUCTION <br /> ELL ... PUBLiC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of We 1 E-xcavatlon '" <br /> Industrial <br /> ' <br /> Domestic/private 7—Drilled Dia. of Well Casingf <br /> +,. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation C Gravel. Pack x Depth of Grout. Sea <br /> Cathodic Protection RotaryType;-of-Grouts ' <br /> Disposal Other f : Other Information L <br /> h Surface Seal Ins ed b <br /> Geophysical s <br /> PUMP INSTALLATION: . :_...C,o.ntr_acto.r. <br /> Type of Pump H.P. <br /> � r <br /> PUMP REPLACEMENT: QState Work Done 't- <br /> PUMP <br /> PUMP REPAIR: Q State-Work Done <br /> ' A rox�imate Depth <br /> DESTRUCTION OF WELL: Well Diameter; �: pp <br /> Describe Materia �an roce ure <br /> I hereby certify-thatYl., have#prepared nth-is-application and that the work will be -done in accordance <br /> with .$aR Joaquin County bi,dinances, 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. R F <br /> laws of California. <br /> I MILL CALL-FOk GROUT -IN CTION PRI TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE: DATE: '" <br /> L:MAWP ON REVERSES D£ <br /> F R DEPARTMEN USE ONLY <br /> /� 'v DATE 2" - f <br /> APPLICATION ACCEPTED BY <br /> . ADDITIONAL COMMENTS: ! wo �l <br /> PHASE II GROUT: INSPECTION PHASE III FINAL INSPECTION <br /> }INSPECTION BY Iv/A DATE INSPECTION BY DATE- <br /> FW <br /> 7' <br /> v--- 9, <br /> Gu 1Q 9F, Rau78 2M_ 4/7R - <br />