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�- --=--=-- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �_IQ FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued_2-,�5-2� <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 herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ),T L �f "' CITY/TOWN <br /> Owner' s Namet2,r- <br /> E r Phone 7, � ? <br /> Address 1- <br /> C C i ty L. „� <br /> Contractor' s Name Li cense# 5. -Phone ,--9'7­_ <br /> IS CERTIFICATE OF WORK'1AN'S CO};PENSATI0111 INSURA110E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL$4 DEEPEN ❑ RECONDITION Q DESTRUCTION-E-1 <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER (. <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK 2_0o 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 /> -IndustrialCable Tool Dia. of Well Excavation ``• C <br /> _�_Domestic/pr.ivate Drilled Dia. of Well Casing l c? <br /> Domestic/public Driven Gauge of Casing_ j,, n <br /> Irrigation. Gravel Pack Depth of Grout Sea y <br /> Cathodic Protection Rotary Type of Grout /0 y/,_ � <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br />'PUMP INSTALLATION: Contractor <br /> Type of Pump 5,. mr ? ! H.P, - - <br /> RUMP REPLACEMENT: 7IState Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION -OF WELL: Well -Diameter Approximate Depth ap � <br /> Describe Material and Procedure ---- <br /> 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> with Sar Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <br /> Health District. !-come owner or licensed agent' s signature certifies the following : <br /> ”- certifythat in the <br /> 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 CA4)L FOR IDIOUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED t � 1� P.-..- � '-a, TITLE: Oo, DATE: � . <br /> DRAW PLOT PLAN ON REVERSE SIDE T <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> r� <br /> AP�f__',ATION ACCEPTED BY , �1 DATE -7//,� 7 <br /> ADDITIONAL COMMENTS: f � <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> 'NSPECTION BY DATE INSPECTION BY DATE <br /> Lei 14 26 Rev. 9/78 5/79 2N r <br />