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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0.w FF11 USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ,79/9 7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued.3- -Z <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. �! '�. (o �o h ,� rz']•'�r ,���, �t d� <br /> EXACT STREET ADDRESS - _tL5 CITY/TOWN She A./ <br /> Owner's Name r- - � Rhone <br /> -- .r �—�--Z��'3 <br /> Address —� <br /> M � City � �``� ��' � <br /> .Contractor's Name _ License Phone <br /> IS GERTIFI ATE OF WORKMAN'S COMPENSATION- INSUR cE ON Pi LEY WITH SJLHD? YES `r 0 <br /> TYPE OF WORK (Check) : NEW W£LLU;}- DEEPENO RECONDITION DESTRUCTION <br /> WELL CHLORINATION n . WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION ❑;. PUMP REPAIR©- PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC .TANK, SEWER LINES j'U� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD/ not CESSP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELLS PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF-WELL., CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> z— Domestic/private Drilled Dia. of Well .Casing <br /> ,_._Domestic/public Driven Gauge of Casing r s <br /> 57 ZZ <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> ______..Cathodic Protection Rotary Type of Grout <br /> ,_ <br /> _ Disposal Other Other Information <br /> _Geophysical Surface Seal Insta ed b . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. <br /> LUMP REPLACEMENT: p State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL Well DiameterApproximate Depth <br /> Describe Materya an Procedure <br /> thereby 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 /> Hbalth District. Home owner or licensed agent's signature certifies the following: <br /> "I,,certify that in the performance of the work •forkwhich 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 SAND FINAL INSPECTION. <br /> SIGNED TITL • DATE: ' <br /> D P T L N ON REVERSE IDE <br /> PHASE I FOR D PART-EN USE ONLY , <br /> TF—PLICATION ACCEPTED BYA/1zDATE ,z <br /> kDDITIONAL COMMENTS: <br /> /?<; <br /> PHASE II GROUT INSPECTION <br />'NSPECTION BY PHASE II FINAL INSPECTION <br /> DATE - 4-�� INSPECTION BY DATE -15-- 9 <br />:H 14 26 Rev. /78 9/78 2M <br />