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`_11 'SAN JOAQUIN LOCAL :H:EALrH DISIRICT <br /> HR FFICE USE: 1601 E. Hazelton Ave:, Stockton, CA 95205 Permit No. 7�-2�/ <br /> Telephone.: (209)' 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /6 ? <br /> This . Permit Ex ires .1 Year From Date 'Issued <br /> Complete In Triplicate y <br /> Application is hereby made to the San Joaquin='Local-, Health District fora permit to ,construct <br /> and/or install -the work herein described. This .-application is, made in .compiiance 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 S . <br /> CITY/TOWN� aI l Z6 <br /> V 74 <br /> Owner's Name Phone - <br /> Address Ci <br /> Contractor's Name - -- T - --.. License / PhoneyrJ—�2f/D <br /> IS CERTIFICATE OF WORKHAN'S COMPENSATION! INSUR HICE ON' FILE'WITH SJLHD"? YES NO <br /> CIA <br /> TYPE OF WORK (Check) : NEW WELLVQ. DEEPEN ❑ RECONDITION C3 DESTRUCTION F1 ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER O Y v <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP,- REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRIVY <br /> SEWAGE DISPOSAL FIELDA^�L CESSSSPOO L/SEEPAGE PIT -- OTHER <br /> PROPERTY L-INVOPRIVATE DOMESTIC WELL"5Q - .PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation `s Z2 IJTIN <br /> �. <br /> � W ll CasinDomestic/private Drilled Dia. of e g_ <br /> Domestic/public Driven Gauge of Casin' <br /> l Irrigation =Gravel Pack Depth of .Grout Sealged. ,by: <br /> Cathodic Protection _Rotary Type of Grout Disposal Other Other. Information <br /> Geophysical Sur6ce'Seal` Insta <br /> PUMP INSTALLATION: Contractor <br /> Type-of Pump H.P. i <br /> PUMP' REPLACEMENT.: [I State Work Done ; <br /> PUMP REPAIR: k. ,,[]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 accordance <br /> 1 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: ° 1 <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 21 <br /> laws of California." <br /> I WILL CALL FORA ROUT�,I E IO IDR TO :G'ROUTING AND A FINAL INSPECTION. <br /> SIGNED ;:' ;`: TITLE- DATE <br /> J[kRAW PLOT PLAN ON REV ER IDE <br /> FOR DEP RTMENT USE ON Y <br /> PHASE I ` <br /> ; APPLICATION ACCEPTED 8Y ZDATE 4A7e <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT-, INSPECTION PHASE II FINAL INSPECTION <br /> ♦ INSPECTION B DATE g- -I INSPECTION BY DATE <br /> '• FH 1d9f; Rpm_ 19-77 . - .._. 1:-/-78- 2M <br />