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.......... _.. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 7 <br /> FFICE USE: ` 1601 E. Hazelton Ave. Stockton, CA 95205 Permit No. '7 �- 5 <br /> Telephoner i20'9) 466--6781 . <br /> 3 - <br /> APPLICATION FOR WELL CONSTRUCTION OR ,PUMP PERMIT Date Issued,5-3l-?. <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 R les..,and' Regulations:.of: the San- Joaquin Local health <br /> District. �7 <br /> EXACT. STREET ADDRESS / . :c - - <br /> s _ <br /> � . _ CITY/TOW <br /> �lOwner's Name <br /> Address Phon <br /> " <br /> C i tC� <br /> Contractor's Name License# D Phone r ~ <br /> - - . _ <br /> IS CERTIF-ICATE OF WOItICiAN'S_COMPFNSATION INSURANCE ON FILE 'WITH SJLHD? M' YES <br /> ' TYPE OF .WORK (Check,) : NEWi WELL M--­ DE-EPEN [] Y -RECONDITION ® DESTRUCTION❑ - <br /> ­WELL�CHL'ORINATION ❑ WELL -ABANDONMENT E3 ' OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑- . PUMP -REPLACEMENT [ � <br /> DISTANCE TO NEAREST: SEPTIC TANK j t'pSEWER LINES PIT PRIVY a <br /> SEWAGE 'DISPOSAL FIELD CESSPOOL/SEEPAGE. PI7— OTHER -- <br /> k ' PROPERTY LINE '- PRIVATE DOMESTIC WELL.. PUBLIC DOMESTIC WELE <br /> INTENDED USS: TYPE-OFA-WELL, � CONSTRUCTION SPECIFICATIONS <br /> Industrial i <br /> ;Cable Tool Dia. of�Well Excavation <br /> Domestic/private '�. .'`Dri 1'l ed Dia. of" Wel 1. Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed b <br /> PUMP.- INSTALLATION: Contractor -- <br /> F Type' .of,Pump <br /> PUMP REPLACEMENT-. .�w <br /> ( ��'Stoto Work Dori ° - <br /> PUMP REPAIR: ❑State Work. Do <br /> !DESTRUCTION OF.WELL. WeA , <br /> Ap.proximate...Depth <br /> N11 "" Descrf be Materia an Procedure <br /> 5 <br /> ;I hereby certify that I have prepared this, appl1cation-and that the work will be 'done in accordai <br /> with' San Joaquin County Ordinances, State Laws , and Rules and Regulations of_the .San",Joaquin Loci <br /> 'He'alth-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 shal-1 <br /> � ..not employ an � a <br /> y person in such manner as to become subject to Workman's Compensai:ion . <br /> laws of California. ", _ . <br /> i WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED~ <br /> PLT—NON TITLE:- DAT • -5,Q, )2 <br /> Q WPL T <br /> REVERSE S-IDE <br /> PHASE .1 FOR DEPARTMENT USE -ONLY <br /> i M <br /> APPLICAT �. <br /> ION ACCEPTED BY r[c� �- ' DATE <br /> ADDITIONAL COMMENTS: <br /> iPHASE II . GROUT INSPEC ION . " PHASE III FINAL INSPECTION <br /> i'NSPLUTION BY DATE - . 'INSPECT'ION BY <br /> 'EH 14 26 Rev. 9/78 DATE /a 1i 7 <br /> }` :a _ __ m rCO,78 29 <br />