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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 4 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued } <br /> A 3W (C.gmplete 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. <br /> EXACT STREET ADDRESS ?-5 CITY/TOWN Sic <br /> Owner's -Name .� asnPhone <br /> Address ``f l?. . ..v. Ile a City . t <br /> Contractor's Name License#aGS-76 Phone�Gy- <br /> IS CERTIFICATE OF WORKMAN'S C01"IPENSATION INSURANCE ON FILE WITH-SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION [n DESTRUCTION <br /> WELL CHLORINATION QWELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR 0- RUMP Q10 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITe P;R 'VY <br /> SEWAGE DISPOSAL FIELD . CESSPOOL. EEPAGE PIS" OTHER <br /> PROPERTY LINE - PRIVATE DOMESTI0 WCLLPUBLIC DOMESTIC WE <br /> INTENDED USE. TYPE OF-WELL... CONSTRUCTION SPECIFICATIONS <br /> .Industrial Cable To Dia. of wel I Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven,,,. Gauge of Casing <br /> Irrigation Gravel -Pack Depth of Grout Sea <br /> Cathodic Protection :Rotairy Type of Grout „ <br /> Disposal . Other = .z Other Information <br /> Geophysical Surface Seal Installed b <br />, PUMP INSTALLATION: - ,Con` tractor&mtv-e it S'� Z _ <br /> _ � .amu A' (_ <br /> Type of Pump 11_.. -� H.P, <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP, REPAIR: (State Work Done :- <br /> DESTRUCTION-OF WELL: We,11 Diameter- - <br /> Approximate Depth � <br /> r- — <br /> I Describ _e Materia I and-Proce ure , <br /> i <br /> y <br /> I hereby certif/thatIl 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..Dist-rict. ;Home owner-,or licensed agent's signature certifies the following: <br /> "I certify thatin the performance of the work for which this permit is issued, �I shall <br /> I not employ any person in such manner as to become subject to Workman's Compensation ' <br /> } laws of Cal i fori i a. " <br /> I WILL CALL FORW ROUT INSPECTION PRIOR TO GROUTING>A.ND A FINAL INSPECTION. _ <br /> SIGNED TITLE• � DATE: / <br /> ' t P T L N ON RE S SIDE <br /> PHASE I R DEP RTME�N SE -O.NLY . - - - -- - - <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE 11_� <br /> PHASE II GROUT INSPECTION <br /> PHASE 11 kLINAL INSPECTION <br /> INSPECTION BY1 t DATE 'INSPECTION BY DATE <br /> EH 14 26 Rev. 9/7,< 9/78 .2M <br />