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{_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> `79 -9 2 3`_ <br /> Telephone: (x,09+ f56-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued&- x-79 <br /> (Complete Ir 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 p --ke-%nA So <br /> b. CITY/TOWN <br /> Owner' s Name A YG- 4�P-4 A. 4 ic-i Phone z— Sr <br /> Address , '' Ci ty <br /> ,Contractor' s Name License iy Phone C1 <br /> IS CERTIFICATE- OF W0RK'iAN S COMIPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLIQ DEEPEN C1 RECONDITION ® DESTRUCTION( �p <br /> WELL CHLORINATION 0 WELL ABANDONMENT O OTHER E3 � <br /> PUMP INSTALLATION C7 PUMP REPAIR❑ PUMP REPLACEMENT C Q <br /> DISTANCE TO NEAREST: SEPTIC TANK /[/L- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ` <br /> F 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 v <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed b <br /> r PUMP INSTALLATION: Contractor l lnrc:- <br /> Type of Pump t .Sa _ H.P. fir. <br /> G PUMP REPLACEMENT: [] State Work Done. <br /> -PUMP REPAIR: ❑State Work Done <br /> " . DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordan+ <br /> •.-Oith San Joaquin County Ordinances , State Caws , and Rules and Regulations of the San Joaquin Loca <br /> Health District. Nome owner or licensed agent' s signature certifies the following: <br /> "T 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 /> 4, I WILL CALL FOR A G OUB NSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DRAW PLOT PL N ON REVERS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> APPLIT <br /> CATION ACCEPTED BY DATE Jury <br /> . ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> -INSPECTION BY ,1,� DATE /p-5 ?y INSPECTION BY ,4 —� DATE// V <br /> a <br /> 5/79 2M <br /> i L11 14 26 Rev. 9/78 - <br />