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/ ~ <br /> V SAN JUAQUiN.. LOCAL .HEALTH piSiKil;1 <br /> F6UFFICE USE: 1601 E. Hazelton.. Ave. , Stockton, CA 95205 Permit No.,­ �r1' <br /> Telephone':_ (209,) 466-6781 <br /> Date Issued -7, `z/-7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Th#is Permit Expires 1 'Year From Date . Issued <br /> Complete In 'triplicate <br />[ Application is hereby made to the San Joaquin 'Local, Health District foraP ermit to construct <br /> and/or install - the work herein described. : -This application is made in with San <br /> �oaQuin County. °Ordinance No. 1862 and the Rules and Regulations .of the San. Joaquin Local Health <br /> IDistr�ct. <br /> EXACT STREET ADDRESS ` (/ 1 � a ' CITY TOWN <br /> I STS ,�ry <br /> Owner' s Name , fPhone c16- <br /> Address. <br /> }6— d <br /> Address Cit <br /> Y 57b� <br /> Contractor' s -NameIteefael-Name~ Li cense# 2.6 -7,61 Phone 11,6 g P -7191 <br /> IS CERTIFICATE OF WORKHAN'S COM PENSATIO"f INSURANCE ON FILE WITH SJLHD? YES NO <br /> i <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER <br /> PUMP INSTALLATION []-- PUMP REPAIR❑ PUMP REPLACEMENT E] <br /> DISTANCE TO NEAREST: SEPTIC' TANK �D _ SEWER LINES PIT PRIVY <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT/ev' OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PURL C ESTIC 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 <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> 42 <br /> Type of Pump H.P. <br /> ! <br />' PUMP`REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Procedure <br /> 1 � <br /> I hereby certify ,that I have prepared this application and that the work will be done in accordance <br /> with San JoaquiniCounty Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Horse-owner or licensed agent' s signature certifies the following: <br /> "I certify thatI.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 FOR A GROQT� NSPECTION PRIOR TO GROUTING AND AJINAL INSPECTION. { <br />;SIGNED TITLE: DATE: <br /> �4 <br /> ���DR PLOT PLAN- ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BYDATE 2 l 7P <br /> ADDITIONAL COMMENTS . - <br /> PHASE_.II .GROUT—INSPECTIO — �-- ---,-- ,PHASE--II-I-- EI-NAL—1-NSPECTION"'-".. <br /> INSPECTION BY DATE.= DATE 1 ,� INSPECTION BY �', DATE ,z 7 <br /> EH 1426 "Rav_ 19-77 <br />