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. �� <br /> SAN JOAQUI.. -LOCAL HEALTH DISTRICT- - - <br /> FFICE USE: 1601 E. Hazelton -Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued F- 3- 7i' <br /> - ,3- 7i' <br /> This Permit Ex fires I Year From Date, Issued <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 incompliance with San <br /> L'oaquin County Ordinance No. 1862 and the"Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN /gAL <br /> �c <br /> Owner's Name ,e YJ <br /> Phone l <br /> 17) <br /> Address ! City <br /> Contractor's Name License# Phone' <br /> IS CERTIFICATE OF WORKf1AN'S COMPENSATIO"J INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL L}- DEEPEN Q RECONDITION ❑ DEST:RUCTION[3 <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR Cl PUMP REPLACEMENT E] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 /> irrigation ,e, Gravel Pack Depth of Grout Seal <br /> Cathodic Protection A- R"otary Type of Grout �?�,�, <br /> Disposal Other Other Information "— <br /> Geophysical Surface Seal Instal ed b <br /> 5. <br /> PUMP INSTALLATION: r Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: __C1 State Work- Done <br /> PUMP REPAIR: Q State Work -Done ' <br /> DESTRUCTION OF WELL`: Well Diameter « <br /> Approximate Depth 07"5 <br /> Describe MateriaT and Procedure , <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> Frith San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Local <br /> lealth District. Home owner or licensed agent's signature certifies �the. foTlowing: <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 asi'to become subject to Workman 's Compensation <br /> Taws of California. " w <br />[ WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION.. u <br />;IGNED TITLE; " DATE: <br /> DR W PLOT PL N ON REVE SE SIDE <br /> FOR DEPARTME <br />'HASE I T USE ONLY <br />,PPLICATION ACCEPTED BY -- <br /> LDDITI�ONAL COMMENTS` <br /> w DATE- _ - - - t <br /> PHASE II GROUT INSPECTION V PHASE 14L FINAL- INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE 5-e-9-79 <br /> H 1426 !RPV- 19-77 l�i? C�a G� �e.� � _a— 2 - - <br />