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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F� FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA - 95205 Permit No.7?-/,;t 9� <br /> Telephone: (209) 466-678L <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ,2,5->> <br /> ins This Permit Expires 1 Year From Date Issued <br /> Complete Iri Triplicate) O'e-`t--old: <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 Or�di nance Flo. 1862 and the Rules and Regulations of the San. Joaqui n Local Health <br /> District. <br /> EXACT STREET ADDRESS r " }- CITY/TOWN <br /> Owner's Name LV z�r•�z -- -€��� ..� . ... <br /> Phone <br /> Address _ ---r_ .s - City rL ` <br /> Contractor's Name License#r f • 77 -Phone <br /> IS CERTIFICATE OF WORKMAN'S CO1iVFN ATIOi1 INSURA"!CE ON FILE WITH SJLHD? YES 11,10 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION [] DESTRUCTION❑ ' <br /> WELL CHLORINATION C7 WELL ABANDONMENT ❑ OTHER ❑ � <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT E3 r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> y PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing kMl <br /> Domestic/public Driven Gauge of Casing <br /> ` Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - f r-1� .,, -- -- ------ H.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP lF-QTR: ❑State Work Done - <br /> � _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> -Describe Material 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- licensed 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 CAL FOR A GROUT INSPECTION, PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> ! s � .rTITLE:SIGNED_ -47xde'� / :� �� � DATE:REVERSE SIDE,oDRAW PLOT PLAN ON 1 { " <br /> FOR DEPARTMENT USE ONLY _ <br /> PHASE I rr , i, <br /> APPLICATION ACCEPTED BY-, " '� "" 'DATE <br /> ADDITIONAL COMMENTS: .. _ \ <br /> PHASE II GROUT INSPECTION PHASE IJI FINAL INSPECTION_ <br /> INSPECTION BY DATE INSPECTION BY DATE <br />!H- 1426 Rev. 12-77 _--_- <br /> 1:/78 2M <br />