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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, TtA 95205 Permit No. -'5-5 <br /> -- Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR' PUMP PERMIT Date Issued i`/3'' <br /> This Permit Expiresl Year From Date Issued <br /> Complete In Triplicate . . <br /> Application is hereby made to the San Joaquin Local Health District -for a permit to cont trdct' <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 2CITY/TOWN <br /> Owner',s Name '57"At Phone /• <br /> Address' ^? r� u%� City <br /> Contracto.r'.s Name i4j.lev Li cense#SJ/77,0 Z- Phone_Y!Z'7 9(Zl- <br /> , <br /> IS CERTIFICATE OF-140P, 1A-rVS CO""�PENSATIO`I Ii3SURA"!CE OPl FILE WITH -SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION [ DESTRUCTION <br /> WELL CHLURINATION WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES d PIT PRIVY--41, <br /> ._ . SEWAGE DISPOO A ,,FIELD CES-SPOOL/SEEPAGE PIT OTHER:19— <br /> y PROPERTY LINEM, PRIVATE DOMESTIC WELL .49_.__. PUBLIC DOMESTIC WELL-a- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia:, of WelT, Excavation Ys% <br /> Domestic/private T DriIIed Dia. of Well Casing 1. <br /> Domestic/public Driven Gauge of Casing 1A6 prrc- <br /> Irrigation TIGravel Pack Depth of Grout-Seal , - <br /> Cathodic Protection Rotary Type of Grouteak.�n•� <br /> Disposal Other Other Information <br /> Geophysical Surface Seale Installed by:S20 <br /> PUMP INSTALLATION: Contractor ZjAj <br /> Type of Pump .Sc4G .# H.P. <br /> , <br /> PUMP REPLACEMENT: []State Work Done _ <br /> PUMP REPAIR: E]State Work Done_ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia 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�1 -ic-ensed<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 FOR A GROUT INSP 0 ION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED w TITLE: DATE: 3-/3 7,eF <br /> r,j DR W PLOT PLAN ON REVERS SIDE <br /> 2.15 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE f <br /> ADDITIONAL-COMMENTS: <br /> PHASE,.. II GROUT INSPECTION PHASE III FINAL SPECTION <br /> INSPECTION BY , DATE INSPECTION BY DATE <br />:H 1426 Rev- 12-77 1./78 2M <br />