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/6 4W Xtb_ SANJOAQUIN LOCAL HEALTH DISTRICT_ -A - ' <br /> FFICE USE: 1601 E. Hazelton Aye. , .Stockton, CA 95205 Permit :No. �Q�! <br /> Telephone:): (209) 466-67.81 ;. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> f� This Permit .Ex ires 1 Year From Date Issued', <br /> Complete- In Triplicate <br />( Application is hereby made to the San Jeaqu-in:r.'Local -Health District for a permit to construct <br /> I . <br /> and/or install the work herein des-cr+bed.._. ThAp s appl i catJ on is made in compliance with -San <br /> Joanain County`Lrdinance Nloy�` 2 and the R es and. Regulations of the San Joaquin Local Health. <br /> District. �3 �' <br /> i EXACT STREET ADDRESS 72�4., Som CITY/TOWN <br /> Owner' s Name Phone <br /> Address IV City ' <br /> Contractor' s Name `p License# IM 7w,-"`Phone <br /> IS CERTIFICATE OF WORKMAN'S COMP SATIO"1 INSUlRANCE ON FILE-WITH SJLHD? . YES N0 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN d RECONDITION,® DESTRUCTION[] �p <br /> WELL CHLORINATION 0 ; WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION [)-a PUMP REPAIRCI PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIEF_D ;� CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> 4 INTENDED USE TYPE OF WELL ; CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> k Domestic/private Drilled to Dia. of Well Casing <br /> Dbmestic/public Driven R Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal _ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other t !}. Other Information <br /> Geophysical ;I Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump •t H.P. <br /> - PUMP REPLACEMENT: ❑State Work Done ik <br /> PUMP R: QState Work Done <br /> DESTRUCTION <br /> / ea <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f Describe Material and E[Pr-ocedure <br /> r I hereby certify that I have prepared ,this _application and -that-th6 '_w6rk, wi'll',-be done' i n=ae•cordanci <br /> with San*5Joaquin County Ordinances ,. State�:Laws , and Rules and Regulations of the San Joaquin Local <br /> Health Di stri ct.`-.Home`owner or .l i-tensed age-A's signature certifies the following: <br /> "I certify that J-K the`' performance of the work for which. this permit is issued, I shall <br /> not employ any pers'on�i'n such manner as to become subject to Workman's Compensation <br /> laws of.Cal ifo.rrn•ia, <br /> 1I WILL CALL FOR A GROUT INSPECT P 19 GROUTING AND A FINAL INSPECTION. <br /> • SIGNE : �I TLE: DATE: r <br /> tnQFAW L PLi ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ;APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> PHA5E.IIJJINAL TNSPECTION pp <br /> rINSPECT.ION BY DATE a INSPECTION BY DATE �Dt` <br /> 3, <br /> C11 lA7C ' r)-- 10 '77 � � /7A <br />