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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P��:�EEICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.z9- 1 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR- PUMP PERMIT Date Issued -/( -a <br /> (complete In Triplicate) u <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 incompliance with San <br /> Joaquin County Ordinance No. 1862 a d e Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS e `. f'ryI w 6CITY/TOWN <br /> Owner's Name z �.,. � �,. s ; X �:-' , Phonek r—,—' . �e6 '�6- <br /> Address Ciyfr ri 'r <br /> Contractor's Nami / ON,�1 lz, "I!-' g = License#-"-L'' Phone <br /> r IS CERTIFICATE OF WORKMAN'S CO3MIPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPER. �O RECONDITION Q DESTRUCTION En- <br /> WELL CHLORINATION WELL ABANDONMENT O OTHER 0 __ LA <br /> PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT Ca <br /> DISTANCE TO NEAREST: SEPTIC TANK45`4' SEWER LINES -- PIT PRIVY CA <br /> SEWAGE DISPOSALFIELDf;: - CESSPOOL/SEP1AGE PITS OTHERS <br /> PROPERTY LIN ` PRIVATE DOMESTIC WELL` PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial -Cable Tool Dia. of We 1 Excavation , ; <br /> ) —Domestic/private Drilled Dia. of Well Casing . <br /> ` <br /> Domestic/public Driven Gauge of Casing <br /> irrigation Gravel Gravel Pack Depth of Grout Sea - <br /> Cathodic Protection Rotary Type of Grout ~~~ - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed rru�rt <br /> PUMP INSTALLATION; Contractor <br /> .Type of Pump H. . <br /> PUMP REPLACEMENT: CIState Work Done <br /> PUMP REPAIR: Q 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 accordan <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <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. INSPECTION PRIOR TO GROUTING AND A FINAL -INSPECTION. <br /> SIGNED <br /> TITLE: DATE: <br /> .r.��,� �. <br /> DR W PLOT N ON REVERSE,.-SIDE) <br /> PHASE I <br /> FOR DEP RTMEN�t USE ONLY <br /> � <br /> PLICATION ACCEPTED BY. DATE a <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 14 26 Rev. 9/78 9/78 2M <br />