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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton e , Stockton, CA 95205 Permit No. 7f-772.-` <br />' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT Date issued SAY 2 4 1978 <br /> This Permit Expires 1• Year From Date Issued <br /> k (Complete 'In Triplicate <br /> Application is herebymade to' the San . <br /> �� Joaquin Local Health District for a permit to construct <br /> dnd/or install the work herein described. Thi-s application i's made incompliance with ,S.an <br /> ,"oaquin County Ordinance No. 1862 and the RuTes and Regulations of the San.Joaquin- Local ' Health <br /> strict. t <br /> EXACT STREET ADDRESSV CITY/TOWN <br /> Owner's Name Phone <br /> AddressCityme <br /> , <br /> Contractor' s Name License# 402.373 Phone q16- y'I:,-7-1` <br />_TS CERTIFICATE OF WORKMAN'S CO"iPENSATION I'13SURAINCE ON FILE WITH SJLHD? YES �r NO if <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION Q DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONME T ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR PUMP REPLACEMENT [� <br /> ;r <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL .G <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private t Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection t Rotary . Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type ofl Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: 215eiate Work Done <br /> DESTRUCTION-OF `WELL: WelmlDiameter Approximate Dept <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done. in accordance <br /> with San Joaquin County Ordinahces , 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 /> 1 WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED !i "{ <br /> yv�TITLE: '7-r,, ,� DATE: <br /> (DRAW PLT PLAN ON REVERSE SIDE <br /> 1 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: - - <br /> PHASE II GROUT 'INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' - -78 <br />-.H 1426 Rev_ 12-77 r " - 1 Q Sur <br />