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SAN JOAQUIN 'LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. '7 -is7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 1,1-Z-ZE 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. Ir ►r I P . <br /> EXACT STREET ADDRESS9 gni, X, M Ilelel ��a. r�A" CITY/TOWN <br /> Owner's Name e o A " " c Phone *;'7',2q Z7 - <br /> Address ` t ,rC , /A r -e . City 7�,o <br /> Contractor's Name_, tr S s tv,ell t.f/ Li cense V' d . Phone <br /> IS CERTIFICATE OF WORKMAN'S CO"iPENSATIO`! INSURA1lCE 0m FILE WITH SJLHD? YES 1140 <br /> TYPE OF WORK (Check) : NEW WELL tr DEEPEN O RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0 PUMP REPLACEMENT � <br /> DISTANCE TO NEAREST: SEPTIC TANK 167 '-f <br /> SEWER LINES 167`�`"" PIT PRIVY <br /> SEWAGE DISPOSAL ,FIELDre?'-# CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN �_? PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIE CA IONS t <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 Installedb <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ElState 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 GROUT INSP CTION PRIOR TO GROUTING AND,,A FINAL INSPECTION. <br /> SIGNED TITLE:A1 K-I -$�r _ ,..I DATE: <br /> DRAW PLT PITN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY '" '°'� /// <br /> �' DATE <br /> ADDITIONAL. COMMENTS: " <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> FH 1426 Rev_ 12-77 __ - - - — _ _ 1/78 2M <br />