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I,-,' <br /> SAN JOAQUIN LDCAL HEALTH DISTRICT <br /> --M FEI-E OSE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 y/D/ <br /> -------_._�_ --� Telephone: (209) 466-6781 <br /> �- - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 9- -7 <br /> (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 Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS U _3 1 t o CITY/TOWN <br /> Owner's Name J7) i c- t7\ L, k �7 _ Phone-3 3 V •-,;( <br /> Address `a --x �-,_ -- City A c•_,a. n7, C1 -- <br /> Contractor's Name 6-11A"t-F, 6,-11 Licensee- <br /> hone-) c,/ j-1 3 ti -7 <br /> IS CER'iIFICATE OF WORK-1AN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ 9-) <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0,� PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPtSSAL FIELD CrOM/SEEPAGE PTT-- OTHER � <br /> PROPERTY LINE - PRIVATFWESTIC WELL PUBLTC-WESTIC WELC— <br /> IMTEMaEO USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS nn..CC <br /> n ustr a Cable Too l Dia. of Well Excavat <br /> Domestic/private Drilled Dia. of Well Casing e <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout ea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed y: <br /> PUMP INSTALLATION: Contractors G 4- <br /> Type <br /> Type of Pump b <br /> PUMP REPLACEMENT: R7 State Work Done C <br /> PUMP REPAIR: ❑State Work Done_ — <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - Describe Material an Procedure_ <br /> herphy certify that I have prepared this application and that the work will be done in accordance <br /> wit^ 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, 1 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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ` _ TITLE: DATE: i. <br /> (DRAW PEOT L ON REV S � <br /> DEPARTMENTFOR SE L G <br /> PHASE I DATE <br /> "l'ZTE7CTION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE I. GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECT.ON BY DATE INSPECTION BY + ; ,DATE <br /> 9/78 2M <br /> Eu 14 26 Rev. 9,!78 <br />