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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FiCE USE: 1601 " E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 -- b 9 <br /> it Telephone: (209). 466-6781 <br /> iDate Issued 611,V79_,_ <br /> i� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (EoiT l ete" In Triplicate)-, w, <br /> Application is hereby made to the San JoaquinrLocal "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 /> Di stri ct? 41p A- - <br /> 4 CITY/TOWN <br /> EXACT,­STREET ADDRESS <br /> Owner's Name Phone <br /> h4D-.i s4 <br /> Address ,I - City - <br /> Contractor's Name Licensee Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENr-ATT l INSURANCE ON FILE WITH"SJLHD? YES O <br /> .. TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION [] DESTRUCTION�. �. .. Q <br /> WELL CHLORINATION 0 WELL ABANDONMENTE-i OTHER{] <br /> PUMP INSTALLATION Q PUMP REPAIR 0 PUMP REPLACEMENT 0 <br /> DISTANCE- TO NEAREST: SEPTIC TANKI e Q SEWER LINES U_ PIT PRIVY <br /> ' SEWAGE DISPOSAL FIELD,- CESSPOOL/SEEPAGE 'P,IT OTHER <br /> ( PROPERTY LINE PRIVATE DOMESTIC '.WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE y TYPE OF WELL, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We Excavation <br /> "Domestic/private Drilled Dia.° of Well Casing <br /> Domestic/publicDriven Gauge,,.of Casing 17,75 <br /> Irrigation ravel Pack Depth-' of Grout S� _ <br /> Cathodic Protection yRotary Type of Grout .. _ <br /> Disposal Other Other Informan ; <br /> Geophysical Surface Seal InSta ed <br /> gr <br /> PUMP INSTALLATION: Contractor <br /> Type ,of" Pump � _ H.P. <br /> PUMP REPUACEMENT: Q Stad Wdrk.,Done <br /> :PUMP REPAIR:" ❑State Work~Done <br /> !DESTRUCTION OF WELL: Well Diameter Approximate Depth -" <br /> Describe Material and Procedure <br /> e � <br /> I hereby certify that I have".prepared this application and that the work will be done in accords <br /> with -San Joaquin County Ordinances , State Laws , and Rules and Regulations of .the San-Joaquin -Loc <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 /> lawsljof California. " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE: DATE: <br /> '1 <br /> (DRAW PLOT PLAN ON RE E SIDE <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY DATE �2 /7� <br /> ?ADDITIONAL COMMENTS : <br /> PHASE X1.1 GROUT INSPECTION PHASE III 4INAL INSPECTION <br /> INSPECTIONBY DATE <br /> pp INSPECTION BY DATE <br /> EH 74 .26 "IRev. 9/78 - 4 � GtCF. 9778 <br />