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SAN JOAQUTN LOCAL1HEALTH DISTRICT <br /> FOR <br /> F ICE USE: 1601 E. Hazel-ton Ave. , '-Stockton, CA 95205 Permit No.7ff— �( <br /> Telephone:' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date IssuY 2 � 1976 <br /> This Permit Ex ires 'l Year From Date Issued .. <br /> Complete In Triplicate. <br /> Application is hereby made to the Sari 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 S'7CITY/TOWN LVV <br /> Owner's Name S d I Phone _ <br /> � <br /> `�� o �D/ Ci ty_g,�1,6 t Address ._ <br /> Contractor' s Name License#jf_4� Phone <br /> IS CERTIFICATE OF WORKMAN'S 1r4 ENSATIO'N INSURANCE ON FILE WITH SJLHD? YES X10 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ® DESTRUCTION ED <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ _ <br /> PUMP INSTALLATION ❑ PUMP REPAIR PUMP REPLACEMENT ❑ C� <br /> k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER s�) <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 S <br /> Domestic/private Drilled Dia. of Well Casing x <br /> Domesti-c/pubI i cDriven- -.- -Gauge,-of-Casing <br /> Irrigation Gravel Pack, Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> w Geophysical Surface Seal Installed- by: <br /> PUMP INSTALLATION: Contractor <br /> k Type of Pump : H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ()-a State Work Done o <br /> ' DESTRUCTION- OF WELL: Well Diameter Approximate Depth <br /> Describe Materi.al ana Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordan( <br /> with San Joaquin County Ordinances , State Laws`, and Rules and Regulations of the San Joaquin Lpcal <br /> Health District. : -Home,own.er or licensed agent'.' s signature certi fi es� the 'fol-lowing: , <br /> t <br /> 'I certify ,th , fn 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 /> I WILL CALL FOR A GROUT INSPE _IOR P44kR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED- 'IM4 - TITLE: ,.d° DATE: <br /> 4 or <br /> DR T PLIAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY04L <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE,r-,2# <br /> i <br /> � FN 7 VA Rav-_ •'7 977 1/78 2M- . <br />