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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E.. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (_209) 466-6781 Date Issued b <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT <br /> -(,Complete In Tri pl i'cate) i <br /> t <br /> ;Application is hereby made to the San Joaquirr_L•ocal .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 b. <br /> CITY/TOWN <br /> Phone <br /> Owner's Name Vk <br /> Address <br /> Contractor's Name Licensees—7Phane ►i ZG ,G <br /> IS CERTIFICATE OF WORKf1Afd'S CO ENSATION INSURA�lWON FILE WITH SJLHD? YEStv 0 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN.[] RECONDITION DESTRUCTION. <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHERID — - —�►� <br /> I PUMP INSTALLATION PUMP REPAIR C PUMPREPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY= N <br /> SEWAGE DISPOSAL FIELD CESSPOUL/SEEP,AGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p� <br /> . Industrial Cable Tool Dia. of We 1 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 Rotary Type of Grout :. <br /> Disposal Other Other Information <br /> Geophysical n P Y Surface Seal Inst a . ed b : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: LI State Work Done <br /> PUMP fes-: State Work Dane <br /> - ' h . <br /> DESTRUCTION OF WELL: :. Well Diameter pproximate Dept <br /> - <br /> Describe Materia and Procedure <br /> l � i <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 Sa-n-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 /> f not employ any person in such manner as to become subject to Workman's Compensation <br /> r laws of California'. <br /> I, WILL CRL FOR A GROUT INSP TI PMR TO GROUTING AND A-FINAL INSPECTION. <br /> SIGNE ,) �� <br /> ITL'E. DATE: Gr S <br /> PLOT PPMNON REVERSE SIDE <br /> ORDEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ZAA AL DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTf td PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPE ION QY v DATE <br /> _..., 9 78 2M, <br /> Ffl 14 26 Rev. 9/78 <br />