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SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton,Ave.., Stockton, CA 95205 Permit No. _7 �- W <br /> ` Telephone: , (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -7 <br /> T.6is Permit. Ex ires 1 Year From Date Issued. .,, <br /> Complete In Tri,pl i tate <br /> rApplication is hereby made to the San Joaquin Local, Health District for a. permit to construct <br /> land/or- install the work herein described. This application is: made- in compliance with San - <br /> juloagain County Ordinance rho.` 1862 and -the Rules and .Regulations :of the San Joaquin Local .Health <br /> ' District. <br /> EXACT .STREET ADDRESS _6)ell <br /> � a SQ . CITY/TOWN,,> <br /> Owner' s Name �� - `�f, Phone <br /> Address:: f City zoA <br /> Contractor's Name ci f 1 �; Q/t License " ! 61,r Phone ,� -- l <br /> I IS CERTIFICATE OF WORKMAN'S`:. COMPENSATION INSURAMCE ON FILE WITH SJLHD? YES NO <br /> . TYPE OF WORK (Check): NEW WELL DEEPEN ❑ RECONDITION I1 DESTRUCTION[) <br /> WELL CHLORINAT IGN=B-�---W-E.LL ABANDONMENT p OTHER E <br /> PUMP"INSTALLATION Ca PUMP REPAIR❑ PUMP REPLACEMENT <br /> IDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (n <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 /> M Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public driven Gauge of Casing` <br /> } Irrigation 4, Gravel Pack Depth of Grout Seal <br /> Cathodic Protection " Rotary Type of Grout <br /> Disposal - Other Other Information <br /> Geophysical -- L <br /> Surface Seal Installed bPUMP INSTALLATION: Contractor /' U <br /> t Type'!of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth_ <br /> Describe Material and Procedure <br /> II 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 /> "I certify that in the performance of the work .for which this permit is issued, I shall <br /> 'not employ any person 16 such manner as to become subject to Workman's Compensation <br /> laws of California. " I <br /> . I WILL CALL FOR A-GROUT INSPECTION PRIOR._TOTGROU_T_I.NG AND A FINAL INSPECTION. <br /> SIGNED l /: or TITLE: / �!� DATE: <br /> i <br /> (5RAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I -• ���� <br /> APPLICATION ACCEPTED BY 4~ DATE <br /> ADDITIONAL COMMENTS : i <br /> PHASE_I.I_ ROUT_-t-I:NSPECTION-.t— - - ---PHASE- I-II-FINAL INSPECTION <br /> INSPECTION BY 'DATE ; ' INSPECTION BY a DATE <br /> ru i nuc` nom.. �_�� 1 /78 2M <br />