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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> __E� Fg_Q FICE USE: 1601. E. Hazelton Ave. , Stockton, CA 95205 Permit No._�7 9-755 <br /> Telephone: (209) 465-6781 <br /> } Date Issued7-9- fi9 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (Complete In Triplicate) <br /> 'Ar}plication is hereby made to the San Joaquin Local Health District for permit to construct <br /> and/or install the work here in described. This application is made in compliance with San <br /> 'Joaquin County Ordinance No. X1862 and the Rules and Regulations of the San Joaquin .Local Health <br /> District. <br /> EXACT STREET ADDRESS p / CITY/TOWN <br /> Owner' s NameL . Phone <br /> Ad d re•s s <br /> Al - City <br />„Contractor' s Name - kj A:rnf.- Li cense#/93 2y -Phone7-61 <br /> IS CERTIFICATE OF 1dORK"IAN'S CO" T TIO"! INSURANCE ON FILE WITH SJLHD? YES td0 ' <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ (,�• # <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER-0 <br /> PUMP INSTALLATION [l PUMP REPAIR® PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: - SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD I. CESSPOOL/SEEPAGE PIT OTHER S <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC 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 of Casing <br /> JC Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ' Other Other Information <br /> Geophysical Surface Seal Installed by_: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump P. t3 <br /> PUMP REPLACEMENT: 7 State Work Done <br /> PUMP REPAIR; ❑S.tae Work Done �— <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth } <br /> Describe Material and Procedure <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 Dif'trict. 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 . " I <br /> I WILL CALL FOR A GROUT INSPECT N PR R GROUTING AND A FINAL INSPECTION. <br /> SIGNED ITLE: DATE: � <br /> DRAW PLOT PLAT ON REVERSE SIDE <br /> FOR D PART ENT USf, ONLY <br /> PHASE I <br /> /7 <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITfONAL COMMENTS : t <br /> PHASE II GROUT INSPE <br /> PHASF, II. FINAL INSPECTION <br /> INSPECTION BY DATE IN CTION BY DATE 1� 7 <br /> U1 14- 26 Rev. 9/78 5/ 9 4 <br />