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SAN JOAQUIN LOCAL HEALTH [DISTRICT <br /> PFIGc USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> Telephone: (209) 466-6781 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued�5 - .� <br /> i <br /> This Permit Expires 1 Year From Date Issued <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. I /� (1-o+ <br /> t <br /> EXACT STREET ADDRESS � /4 3 GAie'- ko W CITY/TOWN !�4121el <br /> Owner's Name � >~ C ` e - Phone 72�. - �' S <br /> Address Gio City .,mac <br /> Con'tractor' s Name_ 11U 11 01ts Li cense#AL1 14 Phone <br /> IS CERTIFICATE OF WORKMAN'S C011PENSATIO'N INSURANCE ON FILE WIT1-1 SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ PRECONDITION ❑ T DESTRUCTION❑ � r' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 <br /> UMP INSTALLATION [23PUMP REPAIR❑ PUMP REPLACEMENT [I <br /> DISTANCE TO NEAREST: SEPTIC TANK /a b SEWER LINES loa PIT PRIVY <br />'. SEWAGE DISPOSAL FIELD ® a CESSPOOL/SEEPAGE PIT OTHER <br /> �ROPERTY LINE -, PRIVATE DOMESTIC WELL fa. 'PUBLIC DOMESTIC WELL 0 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Wel Excavation a " <br /> Domestic/private Drilled Dia. of. Well Casing t, If <br /> Domestic/public Driven Gauge of Casing � C ! , <br /> Irrigation - DC Gravel Pack Depth of Grout Seal S D.r <br /> Cathodic Protectiion X Rotary Type of Grout (2 e Im ,t7 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed b err- � `' <br /> PUMP INSTALLATION: _ „ Contractor r`, eo- <br /> Type of Pump H.P. �-- <br /> PUMP REPLACEMENT: p State. Work Done <br /> ` PUMP REPAIR: i ❑State..Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> -Describe Material and Proce ure f- <br /> I hereby certify that I1have prepared \this application and that the work will be done in accordant( <br /> with San Joaquin Count ' 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 /> k "I certify that in tfie 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 GROUTiINSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> i&"SIGNED � ..�` TITLE: WCL ,r DATE: <br /> >; ,,; gyp. (DRAW PLOT PL N ON REVERSE SIDE <br /> t:. FOR DEPARTMENT USE ONLY ;77— <br /> 'P,HASE .I DATE T <br /> PLICATION ACCEPTED BY IM.4 <br /> ADDITIONAL COMMENTS: t� <br /> - PHASE II OUT INSPECTION AHA I INAL INSPECTION <br /> 4 INSPECTION BY f DATE INSPECTION BY DATE <br /> FH 1426 Rev_` 12-77 = �� _ _ - /7 8 2M.... <br />