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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FIUR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. d� <br /> Telephone: (209) 466-•6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ 3_ <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 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 0.53 Qjer2�/q C�cr9�z -42�,6 , . CITY/TOWN .�� y <br /> Owner's Name 1010L/ Phone <br /> Address .3 7- City <br /> Contractor's Name J.,vl U' togA,a V, i c e n s e# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOt,! INSURANCE ON FILE WITH SJLHD? YES v 0- <br /> TYPE OF„ WORK (Check) : NEW WELL a DEEPEN ❑ RECONDITION ❑ DESTRUCTION[� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION &O-- PUMP REPAIR❑ - PUMP- REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LIN�S-rD/ PIT PRIVY <br /> SEWAGE DISPOSAL IELD ZW CESSP OL/SEEPA�E PIT OTHER <br /> PROPERTY LINE MPRIVA E DOMESTIC WELL,_ PUBLIC DOMESTIC WELF <br /> INTENDED USE' TYPE OF-WELL.. CONSTRUCTION SPECIFICATIONS <br /> In ural Cable Tool Dia. of We Excavation Q <br /> - <br /> ��-Domestic/private Drilled Dia, of Well Casing <br /> Domestic/publicDriven Gauge of Casing <br /> Irrigation Gravel �k Depth of Grout Sea <br /> Cathodic Protection Ro ry Type of Grout <br /> _____Disposal Other Information <br /> Geophysical Surface Seal Inst a e <br /> PUMP INSTALLATION: Contrac �� / � <br /> Type of p H.P. <br /> PUMP REPLACEMENT: [7 State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material. and Proce ure <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 INSPECTION PRIOR TO GROUTING ANQ FINAL INSPECTION. <br /> SIGNED TITLE- DATE: 3 , <br /> D FOR <br /> ON REVERSE SIDE <br /> PHASE I DEP RTMEN SE ONLY <br /> PfPLICATION ACCEPTED BY �� ; DATE <br /> 2/7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 14 26 Rev. 9/78 _ 908 2FF <br />