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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.Zg-Z,,W 8' <br /> Telephone; (209) 466--6781 <br /> (APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 79, <br /> _ <br /> This Permit Ex 'ir.es 1''Year From Date Issued <br /> ,i Complete In 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 Ordinancel,No. 1862 and the Rules and Regulations ..of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRE S et4pCITY/TOWN <br /> Owner's Name r Phone <br /> ;E <br /> Address - _ Ci ty. <br /> Contractor's Name�l ' .1� 7 Li censeg&a& Phone <br /> IS CERTIFICAW6 I 0K iA�N�S O,IPENSATIO"I I,ISURAklCE ON FILE WITH SJLHD? YES `� NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN [IRECONDITION C] DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER ❑ <br /> PU <br /> ilIMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT M <br /> DISTANCE TO NEAREST: SIEPTIC TANK SEWER LINES PIT PRIVY V <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 /> Domestic/private : Drilled Dia. of Well - Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal �"� - - Other �� ` Other ' Information '- - T <br /> Geophysical.." --�.� ��-. ..m�Y. ...-x- _ __. -Surface Seal. Insta led .b -- <br /> IPUMP INSTALLATION: Cpntractor d <br /> T pe of Pump H.P. �3 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> E <br /> PUMP REPAIR: 'OState Work Done <br />'DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> k Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordancE <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 in such manner as to become subject to Workman 's Compensation <br /> law5 of California.';E <br />� I WILL CALL FOR A GROUT : NSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> FSIGNED 4 TITLE: DATE: <br /> i�. <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> I FOR DEP RTMENT USE ONLY <br /> PHASE I I <br /> APPLICATION ACCEPTED BYI' DATE Id - 3')17b <br /> ADDITIONAL COMMENTS: Ip <br /> PHASE II GROUT (NSP CTION PHASE III FINAL INSPECTIO <br /> JN <br /> INSPECTION BY IN DATE INSPECTION BY - - DATE <br /> I PW 1 d9A oo„ 1,7-77 1' __ -1 /78 2M <br />