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�- —*"to 4. sumer SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> __MfFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. _7-?7 <br /> Telephone: (209) 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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 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 / cr � 4 04 Sam- <br /> ...,__...._.. r)�,R h,-- ITY/TOWN <br /> Owner's Name :- 6s:d, ay, /gyp o_4y Phone <br /> Address 4?40 City gm/_ <br /> Contractor' s Name License# 1S3 7"' Phone F Y -?67-` <br /> IS CERTIFICATE OF WORK"SAN'S CO"1P a ATIO"i INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK .(Check) : NEW WELL 0 DEEPEN ❑- RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT M OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT EW <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _)Domestic/private Drilled Dia. of Well Casing. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump zk H.P. �- <br /> PUMP REPLACEMENT: s State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 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 /> "1 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 IN CT 0 -R. OR TO GROUTING AND A FINAL INSPECTION. <br /> S I G N E TITLE : ro.T DATE:- <br /> -(DRAW <br /> ATE:DR W PLOT PLWN ON REVERSE SIDE <br /> PHASE <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY z DATE .21-19I <br /> ADDITIONAL COMMENTS : <br /> PHASE Ii GROUT INSPECTION PHASE U I INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE,_L <br /> LH '426 Rev. 9/7� 5/79 2M <br />