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FFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - -- 1�601�E. Hazelton Ave. , Stockton, CA 95205 Permit No. 9.,5 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date IssuedS=,� -,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 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 /> Phon -5 7 <br /> ell <br /> Address I <br /> City <br /> Contractor's Name ' License# Phone(W3)5-71-° <br /> " - 1- < <br /> IS CFRTIFICATE OF WORK411AN'S COMPENSATION INSURA1110E ON FILE WITH SJLHD? YES 0 <br /> TYPE OF WORK (Check) : NEW WELL EI DEEPEN 0 RECONDITION Q DESTRUCTION F1 <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER K1 ._ &SmtG <br /> PUMP INSTALLATION 0 PUMP REPAIR L7- PUMP REPLACEMENT <br /> DIS-- T� TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PI-T OTHER <br /> PROPERTY LINE - PRIVATE D MESTIC WELL _. PUBLIC DOMESTIC WELL <br /> INTENDED USE <br /> TYPE OF-Jff*E-..AoLG CONSTRUCTION Til SPECIFICATIONS <br /> .Industrial Cable TDia. of Wel Excavation ' <br /> Domestic/private Drilled Dia. of Well Casing <br /> --- iDomestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> _� Cathodic Protection _ M'� <br /> D =Rotary� y Type of Grout . <br /> Geophysical Other Other Information <br /> Surface Seal Instalbd by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter �t <br /> Describe Materia an e Proce ure , Ap roximate Depthlo' � ' <br /> wwT- <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <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 Ca fornia. " <br /> I WILL CA F R A GROUT I PECTION PRIOR TO GROUTING AN A FINAL INSPECTION. <br /> SIGNED '- <br /> TITLE: +� DA 5;-/9,9/-79. <br /> MRAW P L N ON REVERSE SIDE <br /> PHASE I ZEP RTM NT USE ONLY <br /> APPLICATION ACCEPTED <br /> ADDITIONAL COMMENTS: DATE , <br /> PHASE II <br />[NSPECTION BY GROUT INSPECTION PHASE III 'FINAL INSPECTION <br /> DATE <br />=H 14 26 Rev. INSPECTIOJ ,BY �DATE� <br /> G 9/78 .2M <br />