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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF USE: 1601 E. Hazelton Ave. ; Stockton, CA 95205 permit Nn. <br /> _ Telephone: (209),. 466-678129 L <br /> APPLICATION FOR WELL CONSTRUCTION_ OR PUMP PERMIT Date Issued `6 ' z t-�9 <br /> (.t omplete In Tri.pl date) _ <br />' Application is hereby made to the San Joaquin Local Health District fora permit1to 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 - CITY/TOWN <br /> Owner's Name <br /> :Address <br /> � Phone <br /> C i ty l <br /> Contractor's Name License# <br /> -7 pane' <br /> I5 CERTIFICATE OF WORKMAN'S CO".P SA IOPd I ON FILE WITH SJLHD? YES 0 ' <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION <br /> WELL CHLORINATION DESTRUCTION <br /> f D WELL ABANDONMENT ® OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR M PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ .., v PIT PRIVY F� <br /> 4 SEWAGE DISPOSAL FIELD CESSP L/SEEPAGE PT7­ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL.r PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS y <br /> Industrial Cable Tool Dia. of dell Excavation - <br />�h _Domestic/private <br /> DomesDrilled Dia. of Well Casing <br />_ tic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic' Protection Rotary <br /> _Disposal . Other Type of Grout - <br /> eophysical �----� Other Information <br /> PUMP INSTALLATION: Surface Seal Installed by: <br /> Contractor <br /> Type of PumpAWN <br /> 11,::ir21E:e doe? H.P.__ <br /> PUMP REPLACEMENT: COState Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION 01-WELL: , Well Diameter <br /> Describe Material an . Proce ure Approximate Depth <br /> I hereby certify that I have prepared this application and that the work will be done in accordance.' <br /> vith San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Local <br /> iealth 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 />'WILL CALL FOR A GROUT I TI PRIOR 0 GROUTING AND A FINAL INSPECTION. <br /> IGNE . <br /> T`L E r DATE: <br /> L ON REVERSE SI E <br /> HASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION°ACCEPTED BY m <br /> DDITIONAL COMMENTS:- DATE <br /> PHASE. II GROUT INSPECTION <br /> 4SPECTION BY DATE PHASE III FINAL INSPECTION <br /> 1 14 26 Rey. 9/78 - INSPECTION BY t DATE <br />