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SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7f---�-3�0-3 <br /> Telephone: (209), 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued ?J� <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. r .This application is made in compliance with San <br /> kloaq'uin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local 'Health <br /> District. IBJ&8 <br /> EXACT STREET ADDRESS m " CITY/TOWN <br /> Owner' s Namecfjla RAA!1w9 ISE Phone jy f- ;gM-1A <br /> I <br /> Address <br /> Contractor's Name License#.2(,>] (J Phone !�e 40' ��"�> <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO1111 INSURANCE N FILE WITH SJLHD? YESy NO <br /> TYPE--0F.--WORK (Check) : NEW-WELL❑-- DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION Com- PUMP REPAIR❑ PUMP REPLACEMENT ❑ I <br /> DISTANCE TO NEAREST: SEPTIC TANKJO' � SEWER'- LINES JW IT PRIVY <br /> SEWAGE DISP SO ALFIELD #' Y CESSPO L/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATEDESTIC 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 <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 /> .a <br /> PUMP,MI..NSTAL+LATuION: Cont .arm"cta' Y . <br /> Type of Pump _ _ .RH�P*- . <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done ` ' <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 CALL FOR A GROUJ INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> SIGNEDTITLE: -� DATE:�I <br /> DR PLOT -PLAN ON REVERSE SIDE <br /> FOR DEPARTM NT USE ONLY <br /> PHASEI <br />'APPLICATION ACCEPTED BYLn:;t4ZVL DATE78 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION • PHASE III_FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY . DATE ' r► <br /> EH 1426 Rev. 12-77 1/78 <br />