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-- SAN JOAQUIN LOCAL: HEALTH DISTRICT <br /> P�_/FFICE=USE: 1601 E. Hazelton Ave..,. Stockton, CA 95205 Permit No. 79- 9U <br /> Telephone: (209) 466-678.1 �- `— <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - -21 <br /> (Complete In Triplicate'j: <br /> .Application is hereby made to the San Joaquin Local Health District fora permit to,construct i <br /> and/or install the work herein described. This application is made in compliance with 'San <br /> Joaquin County. Ordinance No. 1.862 and the Rules and Regula.tions. of the San Joaquin -,Local Health <br /> 'District. <br /> 'EXACT'STREET ADDRESSZy <br /> ITY/TOWN. <br /> ,owner's Name Phone— <br /> Address. <br /> Address o'?/ o� I�/1Cd.Y /t Ci ty <br /> Contractor's Name rLicense#hone —7-c 7-6 <br /> IS CERTIFICATE,OF WORKMAN'S COM EN ATION INSURANCE ON FILE WITH SJLHD? YES -1k NO <br /> TYPE OF WOR!< (Check) : NEW WELL M DEEPEN ❑ RECONDITION <br /> WELL CHLORINATION [] WELL A$RNDONMENTT � DESTRUCTION <br /> RT0 N� <br /> , PUMP P INSTALLATION PUMP REPAIR p PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . .,. .- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP L/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL! PUBLIC .D MESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of ,Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> _Domestic/public Driven Gauge ofCasing Nt <br /> Irrigation Gravel Pack --Depth of.Grout Sea <br />____. Cathodic Protection Rotary Type of Grout - - <br /> DisposalOther Other Information <br /> Geophysical _ Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor ' - � <br /> Type of Pump �a.P." H. Ir ` <br /> PUMP REPLACEMENT: M State Work Done <br /> PUMP kE=1R: (RState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Ap oximate Depth <br /> Describe Materi.41 an2 Procedure <br /> I hereby certify. that I have prepared this application and that the work will be done in accordance <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 California. <br /> I WILL CALL FOR A GROUT INSPEC I G TING AND A'FINAL ' INSPECTION. <br /> SIGN ITLE: DATE: <br /> R PL ON REVERSE SIDE <br /> PHASE I <br /> R P RT EN USE ONLY <br /> - -,1 <br /> APPLICATION ACCEPTED BY DATE <br /> kDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ' ' <br /> NSPECTION BY P AS iI FMAE NSPECTrON <br /> /4DATE INSPECTION BY DATE <br />-H 14 26 .Re.v: ,9% <br />