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SAN JOAQUIN .LOCAL HEALTH DISFRICT <br /> 22F.FI•CE.. USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. :1-'1b <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued , <br /> /� This Permit Expires 1. Year Frorh Date Issued <br /> - ! 3� 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 Ordinance -No. 1862' and the Rules and .Regulations of the San JoaquinaLocal Health <br /> District. <br /> EXACT STREET ADDRESS :2_7�_0 C7 A/ 21_0SSoN_ --- __ CITY/TOWN 71/ ,XJ <br /> Owner's Name ,QL%/I11� CDfl��'!" - _ Phone��� ? <br /> Address .4X26q City <br /> Contractor's Name o License# Phone - <br /> 1 <br /> IS CERTIFICATE OF WORKiiAN'S COMIPENSATIOIN IINSURAINCE ON FILE WITH SJLHD? YESNO <br /> TYPE'-OF WORK-(C'heck): - NEW WELLEf DEEPEN ® RECON'DITION,C3' -DESTRUCTION[ T <br /> M. Fi• SEEBECI{ SONS WELL CHLORINATION Q WELL ABANDONMENT p OTHER 0 � ---- <br /> P- 0. Box 552 PUMP INSTALLATION 5ir- PUMP REPAIR 0 PUMP REPLACEMENT ❑ . t � <br /> DISTANCE TO NEAREST: SEPTIC TANK / G�� SEWER LINES / 11) " PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /u';,?�` CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL -/f`_ PUBLIC DOMESTIC 'WELL <br /> .INTENDED USE TYPE OF WELL CONSTRUCTION SPE"F4&ATIONS <br /> Industrial Cable Tool Dia. of Well Excavation a <br /> te-�)omestic/private _ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigationgavel Pack Depth off Grout Se 1 <br /> Cathodic Protection ✓ Rotary Type of Grout y, <br /> Disposal Other Other Information <br /> Geophysicalurface Sea s ta 11 ed �b : l <br /> PUMP INSTALLATION: Contractor L n 5 <br /> Type of Pumpi H.P. <br /> 00 <br /> PUMP REPLACEMENT: E]State Work Done <br /> PUMP REPAIR: Q State Work Done f° <br /> DESTRUCTION-OF-WELL:—Wel1-Di-amet-er` —Approx-ima-te-Deptk; ` <br /> Describe Material and Proce ur <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 /> laws of California. " <br /> I WILL CALL FW A GRqft IN5PECTION2. 4jQR TO GROUTING AND A F A INSPECTION. <br /> SIGNED TITLE: DATE: a� <br /> ADRAW PLOT PLAN ON REVERSE SIDE <br /> y FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED �Y _ _ DATE <br /> ADDITIONAL COMMENTS : 4 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 1. DATE INSPECTION BYE 42gz ( DATE_9 - <br /> EH 1426 -Rev_ 12-77'-. ���_..�� 1/78 2M_ <br />