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co tg/6.4we SAN MAQUIR LOCAL JHEALTH DISTRICT <br />--FOR DICE USE: 1601 E. Hazelton Ave. ,. Stockton, CA 95205 Permit No.`���'�s <br /> Telephone: (209) 46.6-6781 MAY 24 197ff <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP' .PERMIT Date Issued <br /> This .Permit Ex' ire-s I' Year: From Date Issued <br /> F Complete In Triplicate '. <br /> Application is -hereby made tolthe 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 o' Onty Ordinance No. 1862 and .the: Rules and Regulations of; the San Joaquin Local ,Health <br /> District. <br /> EXACT STREET ADDRESS,. L /V--744 Af iAxi- '?W CITY/TOWN <br /> Owner's Name Phone <br /> C i ty LA— <br /> Address , 6 - <br /> Contractor's Name cs- au7 y r` License# l_39YPhone —Z6 � <br /> IS CERTIFICATE OF WORKMAN'S CO"- ENSATIO"l PISURA"!CE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN Q RECONDITION DESTRUCTION <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER I-1 � .-- <br /> PUMP INSTALLATION [] PUMP REPAIR® PUMP REPLACEMENT p <br /> DISTANCE TO NEAREST: SEPTIC11TANK 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 ;i Drilled Dia. of Well CasingI <br /> Domestic/public ':i Driven Gauge of Casing t <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection .1 Rotary Type of Grout <br /> Disposal ' I Other Other Information <br /> Geophysical `" Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor I <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: �]State Work Done <br /> 'PUMP REPA•IR: QState Work Done <br /> DESTRUCTION\OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure t " <br /> I hereby certify that I have prepared thi.s' appl.ication and that the work will be done in accordance <br /> with San Joaquin County Ordinances, State"Laws , `and Rules and Regulations of' the San Joaquin Local <br /> Health District. Home owner yr 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 /> I WILL CALL FOR A GROUT INSP CT ON`. F- H OR TO--GROUTING—AND A F-INAL LNSPECTION.- -• - -�' <br /> SIGNED ITLE: 'DATE: ' <br /> RAW PLOT PL N ON REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY U' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION a <br /> INSPECTION BY DATE _ INSPECTION BY � I DATE s" -,t4 <br /> cu I n'1c D— ' '9 0_'77 . _. .1718 2M , <br />