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SAN JOAQUIN LOCAL HtALIH U15IR1LI <br /> FFICE USE: 1601 E. Hazelton Ave.., Stockton, CA" 952,?5 Permit No.�� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued_5-,;�_9-7� <br /> This Permit Ex ires .l Year From Date Issued <br /> Complete In Triplicate ix <br /> Application is hereby made to the San Joaquin Local Hea-Ith District for permit to construct <br /> sand/or install the work herein described. This application-As made in compliance with San <br /> ,'aanuin County Ordinance No. 1862 and the Rules .and Regulat' s he San Joaquin Local Health <br /> - . <br /> EXACT STREET ADDRESS ` . QCtef CITY/TOWN S cC <br /> Owner's Name r-t 0_J .e. _ CPhone <br /> 1 <br /> Address W-9 012 <br /> Ci ty a K <br /> Contractor's Name a k-,.M_Q, LAJ 0- [2Aicense# IY6 ? 16 Phone 796 <br /> IS CERTIFICATE OF WORKMAN'S r.() ENSATIOij INSURANCE ON FILE WITH SJLHD? YES NO <br /> ITYPE' OF WORK (Check) : NEW WELL W DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> i WELL CHLORINATION 0 WELL ABANDONMENT p _ .OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR:❑.,,.--PUMP"REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK (d o SEWER LINES,.- <br /> je ,0 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD_, CESSPOOL/SEEPAGE PIT OTHER <br /> • 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 . <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ �r,Gravel Pack Depth of Grout Seal Ts <br /> Cathodi c Protection Rotary Type of Grout <br /> Disposal Other ; - Other Information <br /> Geophysical -� - Surface Seal Installed b LZr, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> a <br /> PUMP REPLACEMENT: C]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 An accordant( <br /> wi.th` "&i`Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Hea-lt.h District. Home owner or 1-icensed.•agent-'s -si-gnat-u're cert-ifi•es -the--following-:"- - , <br /> °`Il I certify that i the <br /> y n performance of the work for which this permit is issued, I shall <br /> 4 not eiploy any person in such manner as to become subject to Workman's Compensation <br /> laws of California." <br /> rI WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. "x <br /> A- <br /> S I G N E DI <br /> -SIGNEDI r- <br /> v- TITLE: DATE: <br /> 3 DR W_,PLOT PLN ON REVERSE• SIDE <br /> FOR .DEP RTMENT USE-*ONLY-,%' <br /> PHASE I � ....r„ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ^ e g <br /> PHASE Ir-OUT-,-INSPECTION PHASk 11-1,,FINAL INSPECTION <br /> 'INSPECTION BY DATE - g-72 INSPECTION BY' DATE <br /> JEH 1426 Rev. 12-77 <br />