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o � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ; <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. zz_,,4L? 7 <br /> Telephone:, (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued IQ <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. 1.862 and the Rules and Regulations of the' San- Joaquin Local Health <br />'district. <br /> EXACT STREET ADDRESS 16 !77r CITY/TOWN �g i <br /> Owner's Name Phone 3 <br /> Address C i ty ' <br /> Contractor's Name L.icense#/G 13,9 3 Phone <br /> IS CERTIFICATE OF WORKMAN'S CO`iPENSATION I�dSURAINCE ON FILE WITH SJLHD? YES f NO <br />_ 1 <br /> TYPE. OF WORK (Check)-: —N-EW WEL-Ltj�j" DEEPEN 0. RECONDITI-ON [] DESTRUCTION-(3 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATIONIR PUMP REPAIR 0 PUMP REPLACEMENT ❑ t <br /> DISTANCE TO NEAREST: SEPTIC TANK/ 3o " SEWER LINES/ .)_6 'PIT PRIVY -- <br /> SEWAGE-:DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ii' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Wellcavation �8'' T <br /> Domestic/private I Drilled , Dia. of Well Casing <br /> Domestic/public Driven r Gauge of Casing <br /> Irrigation : Gravel Pack Depth., of Grout Seal s <br /> Cathodic Protection I_ K Rotary ► Type of Grout 1 { <br /> Disposal I Other 4 Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP- REPAIR: , Q State Work Done <br /> DESTRUCTION OF)WELL: Well Diameter I Approximate Depth <br /> Describe--MaterialDbsc'ritib--Matdrial and. Proce ure <br /> .v <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 licensed agent' s signature certifi-es:. the following:, <br /> "I certify that in the performance of. thework for which this permit is issued,. I shall <br /> not employ;any person in such manner4as to become subject to Workman's-Compensation <br /> laws of California." - <br /> I WILL CALL OR A GROUT INSPECTION PRIOR TO GROUTING AND A ,FINAL/ INSPECTION. ; <br /> SIGNED TITLE: _DATE: �"' 7--79 <br /> : DR W PLOT PL N ON_REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> '7 <br /> APPLICATION ACCEPTED BY DATE 9— L?_1 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION s <br /> INSPECTION BY DATE INSPECTION BY C_4 DATE r/- Z ' <br /> ` <br /> rw I J9A Qa„ i�_�7 1/78 2M <br />