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1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT = � , <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.,79_ij-7� T <br /> Telephone: (209) 466-67'81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -7 <br /> (Complete 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 Sari <br /> Joaquin County Ordinance No. 1862 and the Rules and" Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET-ADDRESS r CITY/TOWN <br /> -r--�-" <br /> Owner's NameEJ Q 11 -4 il At - 0-9 led a. A _ Phone <br /> Address oel - City 4, pC/oe <br /> Contractor's Name -License# Phone f- r <br /> w . <br /> IS C.ERTIFICATE•.OF WORKMAN'S-rC.0�1PENSATION' INSURRNCE' N'FIf.E"WITFI SJLHD? YES �=-0 <br /> TYPE'"OF `WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION DESTRUCTION F1 x � <br /> WELL CHLORINATION Q WELL ABANDONMENT ® OTHER 0 � <br /> PUMP INSTALLATION Z1— PUMP REPAIR L7 PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK��� SEWER LINES g7' FPITPRIVY <br /> SEWAGE DISPOSAL'• FIELD 11' CESSP OL/SEEPAGE:1 OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC D MESTIC WEIL � I <br /> INTENDED USE <br /> TYPE-OF.:WEL�� x� CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia, of Well Excavation <br />— romestic/private Dril-l-ed ', . , Dia, of Well Casing <br /> _Domestic/public Driven Y . Gauge of Casing <br /> IrrigationGravel Pack Depth of Grout Seal A <br /> _Cathodic Protection Rotary- *� Type of Grout <br /> „r Disposal. , Other' Other Information <br /> _.Geophysica-1 Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor f cle ivi- `,,,t,. <br /> ' ` • Type of- Pump H <br /> Pf1MP REPLACEMENT: <br /> State=Work-Done ; <br /> PUMP REPAIR: QState= Work Done._ ' <br /> DESTRUCTION 'OF WELL: '"-Well Diameter_ <br /> Approximate Depth <br /> Describe Material and Procedure <br /> t <br />['hereby certify that I Have prepared this' ,application and that the work will be done in accordance <br /> vith San Joaquin County 'Oirdinances, State Laws., and Rules and Regulations of the San Joaquin-Local , i <br /> tealth District-. Homeowner or licensed agent's signature certifies the following: <br /> flI certify that in :` rm <br /> the�. perfoance of the work for which this permit is issued, I shall <br /> not ,employ any person= in such manner as to become sub ' <br /> �� subject to Workman's Compensation <br /> laws- of California. <br />' .'WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. { <br /> SIGNED TITLE: DATE: <br /> D PLT PLN ON REVS SE SIDE , <br /> _4 FOR DEP RTMEN JJSE ONLY <br />'HASE' i <br />,PPLICATION ACCEPTED BY DATE eh <br />,YDITIONAL, COMMENTS: ; <br /> PHASE II _GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE - <br /> INSPECTION BY efDATE -f 7 <br /> H 14 26 Rev. 9/78 9/7$ 2M <br />