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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA. 95205 Permit No, -79-10Z4 <br /> Telephone: - (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued � 4 <br /> (0mplete 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,oRules and Regulations of the <br /> District. San Joaquin Local Health <br /> EXACT STREET ADDRESS p� Sri CITY/TOWN G4Gerl � <br /> Owner's Name Al Phone 76 <br /> Address City ` <br /> Contractor's Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURMICE ON FILE'WITH-SJLHD? , YES 0 <br /> TYPE OF WORK (Check) : NEW WELL CI DEEPEN-®-"RECONDITION DESTRUCTION 0 <br /> WELL CHLORINATION p WELL ABANDONMENT OTHER <br /> PUMP INSTALLATION ❑ . 'PUMP REPAIR 07 1. RU P REPLACEMENT <br /> DISTANCE TO NEAREST: :, SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE -P-17— OTHER ! <br /> PROPERTY LINE. - PRIVATE DOMESTIC WELL— PUBLIC D MESTIC WEE. CJ1 <br /> INTENDED' USE'' TYPE OF WELL.- CONSTRUCTION SPECIFICATIONS ..Ij <br /> _ Industrial— Cae Tool , Dia, of We Excavation } <br /> Domestic/private Drilled Dia. of Well Casing bl <br /> = Domestic/public <br /> Irrigation Driven Gauge of Casing <br /> Irri <br /> . g Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Inst-7--yed <br /> PUMP INSTALLATION: Contractor <br /> _ Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT; v ❑State Work Done <br /> PUMP REP ❑State Work Done R --; <br /> RUCTION OF WELL: Well Diameter ` <br /> ` W-4t roximate-Depth' <br /> Describe Maters a_ andsProce ureas <br /> I hereby certify that ve=prep red tapplicat n ani at t.e,w w1 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�dertifies the following: <br /> "I certify that in-thevperfor�nance-af`the work-for.whish-thi_s�per..m -t i-s- f sued, 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 -INSPECTION PRIOR TO GROUTING AND A FINAL"INSPECTION. �. <br /> SIGNED <br /> TITLE: DATE: . <br /> D W P P N ON REVERSE SIDE <br /> PHASE .I R'DEP RTMENT USE ONLY <br /> PPS LICATION ACCEPTEDaBY <br />%DDITIONAL COMMENTS: DATE � <br /> PHASE II GROUT INSPECTION PHASE TI INAL I PECTIO <br />'NSPECTION BY� DATE <br /> 14 26 Rev. 9/78 INSPECTION BY ' <br />[H DATE <br /> a o f PAI <br />