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SAN JOAQUIN LOCAL HEALTH DISTRICT It. <br /> P� <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 2!l� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _T_12_,7y <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- <br /> Owner's <br /> DDRESS A C CITY/TOWNr�r6v <br /> Owner's Name (,{� `J�_62, 3 <br /> •u rt Phone -� <br /> Address <br /> ci ty__ .5yr c/lnE.M/ <br /> Contractor's Name la ,( U .r f--- License# Phone 3 <br /> P <br /> i5 CERTIFICATE OF.-WORKMAN'S COMPENSATION INSURANC ON"FILEV1TH'-SJLHD? xYES e__ NO. <br /> TYPE OF WORK (Check) : NEW WELL C1 DEEPEN ❑ RECONDITION DESTRUCTION[] <br /> WELL CHLORINATION [I WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION 94- PUMP REPAIR E3 RUMP REPLACEMENT ❑ y <br /> DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES-60" PIT PRIVY <br /> SEWAGE DISPOSAL FIELD -M CESSP OL/SEEPAGE PIT OTHER <br /> PROPERTY LIN 15 PRIVATE DOMESTIC WELL-34",)—.�. PUBLIC D MESTIC WELT <br /> INTENDED USE TYPE OF WELL., CONSTRUCTION SPECIFICATIONS <br /> In Cable Tool Dia. of We 1 Excavation <br /> --Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> - Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> ______Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. <br /> PUMP REPLACEMENT: [I State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mate-r-Ta-1 and Procedure <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° far 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 CIALL FOR A ROUT NSPECTION ,PRIOR TO GROUTING AND &JINAL INSPECTION. <br /> SIGNED �-�•'~' <br /> TITLE: p DATE: <br /> DR PL T L N ON RE E E SIDE <br /> PHASE I FO DEPA TME NT SE ONLY <br /> APPLICATION ACCEPTED BY ' . �, D 1 <br /> ADDITIONAL COMMENTS: ATE L3 j <br /> PHASE II GROUT INSPECTION ---, <br /> INSPECTION $Y DATE PHASE II -FINAL INSPECTION <br />• INSPECTION BY DATE --I5--`I�j <br />=H 14 26 Rev. 9/78 9/78 2M <br />