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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />' FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7q _(0 <br /> y K <br /> ' Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued 6- ?_0-79 <br /> 4 ('romp 1 ete .'I n 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• Regulatiohs of the San Joaquin .Local Health <br /> ,-District. <br /> ff± EXACT STREET ADDRESS CITY/TO N <br /> Owner's Nam .DLe.J <br /> Address Cit <br /> Contractor's Na f'�� License# <br /> 61Z 1-,0P <br /> TS CERTIFICATE :OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES N 0Z---� <br /> TYPE' OF WORK (Check): NEW WELL 0 DEEPEN.p__ RECONDITION Q _ __DESTRUCTION EI s <br /> F I WELL CHLORINATION ( L ABANDONMENT ® OTHER 0 <br /> PUMP iNSTALL4TION,; -.P�,MP,.,REPAI R 0-_ PUMP REPLACEMENT Q w <br /> f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . ' <br /> PIT PRIVY <br /> SEWAGE. DISPOSAL FIELD — -- - CESS__L-/SEEPAGE -PIT OTHER <br /> ,. PROPERTY LINE - PRIVATE,DOMESTIC WELL PUBLIC DOMESTICtI <br /> WELD <br /> INTENDED"SE­ � TYPE OF -WELL.,_W1 CONSTRUCTION SPECIFICATIONS <br /> t Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled' Dia. of Well Casing Y <br /> _ Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> ' Cathodic Protection , Rotary r* Type of Grout <br /> Disposal Other .,� Other Information <br /> Geophysical Surfac Seal Installed by: <br /> PUMP. INSTALLATION: Conir 7tZ)1 � <br /> Type of Pump' H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> f <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 4. Approximate Depth <br /> s <br /> Describe Material and Proce ure <br /> I hereby certify that 'I have prepared this application and that the work will be done in accordarn <br /> With San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca' <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 in such manner as to become subject to Workman's Compensation <br /> ` laws of Aalifornia." <br /> I WILL 'CAL OR A GROUT INSPECTLa 761OR T GROUTING_..AND &4NAL INSPECTION. <br /> SIGNEDDATE <br /> .A TITLE: --C� : <br /> PLAN ON REVERSE SIDE) <br /> E PHAS E I R <br /> F DEPARTMENT USE ONLY <br /> I PP�LICATION ACCEPTED BY DATE /1? <br /> FA'DDITIONAL COMMENTS: - . <br /> PHASE 14& GROUT. INSPECTION -.P:HASE'III FINAL INSPECTION <br /> ;INSPECTION BY DATE.' ',, INSPECTION B1f DATE --2 <br /> ,EH 14 .26 Rev. 9/78 G2-(A. �� �,..�- Stu 4*i - ,.� sa.-- -c�. �� zz �5^'�° -- - <br />