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AS <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 7 <br /> tFOR FFTCE USt: 1 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7j:2— ' <br /> Telephone: i,(209) 466-6781 <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 ¢, CITY/TOWN Zacef-� 4 <br /> Owner's Name Z AaAAOIZ-b Phone ,- )sh_ <br /> Address City y <br /> Contractor's Name License Phone <br /> IS CERTIFICATE -OF WORKMAN'S COMPENSATION IPJSURAM�CE ON FILE WITH SJLHD? YES 0' <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN PO RECONDITION DESTRUCTION <br /> WELL- CHLORINATION 01' WELL ABANDONMENT'M OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT [I N <br /> DISTANCE TO NEAREST:. SEPTIC TANkTj2 1� SEWER LINES .. PIT PRIVY <br /> SEWAGE DISPOSAL IELDS6 °� CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE/O RIVATE DOMESTIC WELL 5�- PUBLiC DOMESTIC. WELL <br /> k " INTENDED USE TYPE OF WELL `CONSTRUCTION SPECIFICATIONS �+ <br /> Industrial ' Cable Tool Dia. of Well Excavationhig <br /> Domestic/private Drilled Dia, of Well Casin " <br /> Domestic/public i Driven Gauge of Casing44 <br /> ,Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodi c Protection Rotary_,,, ., .�, . . Type of Grout Y-~ <br /> Disposal Other Other Information <br /> Geophysical ' ':4 Surface Seal Insta ed b .____ <br /> PUMP INSTALLATION: Contractor <br /> i Type.of Pump <br /> r �UMP REPLACEMENT: r]State Work"Done <br /> PUMP REPAIR:. ' x Q State Work. Done <br /> ( DESTRUCTION OF, WELL: Well Diameter Approximate Depth <br /> Describe material ana Procedure <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 oraicensed 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 fo Workman's Compensation <br /> laws of Californiat <br /> IT WILL CALL-FORA RO . IN TION PRIOR. TO_GROUTING AND A- FINAL INSPECTION. <br /> 1�42 Ala <br /> SIGNED �' - TITLE: DATE: <br /> PL N ON REVERS SIDE <br /> -�' F DEPARTMENT USE ONLY <br /> (PHASE 10 <br /> APPLICATION ACCEPTED BYr P DATE 3-a2fe- <br /> ADDITIONAL COMMENTS: <br /> - PHASE- II GROUT INSPECTION PHASE IIL F NAL JNSPECTION <br /> INSPECTION BY DATE INSPECTION BY W DATE -1 -7 <br /> 9178 <br /> EH 14 26 M <br /> Rev. 9/78 <br />