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i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton-Ave. , Stockton, CA 95205 Permit No. 7Y- <br /> Telephone: (209) 466-6781 z <br /> IDate Issued I/` -� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires l Year From Date Issued <br /> + Complete In Trip .icate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein1described. This application is made in compliance with San <br /> Joaquin County Ordinance No. L862 and the Rules and Regulations /of the San aloaquin Local Health <br /> o_ <br /> District.( /G ���� 7' a) V-5- - .moi- t CITY/TOWN HA•��1i�. <br /> EXACT STREET ADDRESS + <br /> Owner's Name ART: VA�t1 G' V m a1IV rte s Phone <br /> Address f7i4 �/fr`�tr% .woe.{ /fir/9 - City <br /> Contractor's Name /UFS License±, Phones^3.ltSb ' <br /> i <br /> IS CERTIFICATE OF WOPKMAN-S CO'1PENSATIO ! INSURANCE ON FILE WITH SJLHD? YES X NO <br /> TYPE'-OF WORK ,(Clock) : N y14 WEC1=0 DEEPEN ❑ RECONDITION Q DESTRUCTION Fls <br /> WELL CHLORINATION:0 WELL ABANDONMENT D OTHER D <br /> n , PUMP INSTALLATIONS PUMP REPAIR❑ PUMP REPLACEMENJ p , <br /> 11 <br /> DIS-T--NCE-TO -NEAREST:- SEPTIC jTANK WER LINES PIT PRIVY / = ; <br /> SEWAGE DISPOSIVL MELD C SSP L/SEEPAGE PIT OTHER fi t <br /> PROPERTY LINE -. PRIVAT-E—D-WESTIC WELL PUBL•IESTICWELL <br /> INTENDED USE ' TYPE OF WELL CONSTRUCTION SPECIFICATIONS r } <br /> _Industrial Cab a=Tool Dia. of Well` Excavation <br /> a <br /> - Domestic/private Drilled Dia. of We11 Casing p <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Sea <br /> —Cathodic Protection )—Rotary, Type of Grout__ <br /> Disposal ; Others e,,Gther Information — <br /> Geophysical j, ` Surface Seal Insta led by: �f <br /> PUMP INSTALLATION: ContractorH.P. 75 <br /> - <br /> Type of Pump 7nJ6.rW4kg0 C— <br /> PUMP REPLACEMENT: ❑State Work Don 1 <br /> PUMP REPAIR: ❑State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: L <br /> Describer <br /> an rote ure <br /> f <br /> I hereby certify that I have:pr .� <br /> '" pared this?app d lication and that the work will 'be ne in accordant <br /> with San Joaquin County Ordinances, State taws, and Rules and Regulations of the San Joaquin Local <br /> Health -is.trict. Home owner-or -licensed agent's signature certifies the following: <br /> "I certify ttiat- in�the performance of the work for which this permit is issued, I shall <br /> not employ any pers`onrn such manner as to become subject to Workman' s Compensation <br /> laws of California. � , <br /> I WILL CALL FOR A'S UT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION• DATE: <br /> SIGNEDTITLE <br /> D W L T L N ON REVERSE IDES--- <br /> FOR DEP M N USE ONLY <br /> %SE I rY DATE <br /> ..,,,PLfffTION ACCEPTED BY _ <br /> ADDITIONAL COMMENTS: PHASEtIII NAL INSPECTION <br /> PHASE II GROUT INSPECTION--�T "9 - DATE s <br /> `INSPECTION BY DATE INSPECTION BY Y� <br /> 1/78 2M <br /> ecu ,noa oo.. 10_77 N�3 03� — <br />