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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> WFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. -&Zw3 <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 9. lS iRob.ezz CITY/TOWN,5p-e,_-/r-rz0v <br /> Owner's Name_-ama Phone 46-L " L6. _ <br /> Address <br /> City-_:5-7-&r_`t'n'"i <br /> Contractor's Name License#;lPhone_� 5`__If 909 �_� <br /> IS CERTIFICATE OF WORK'1A14'S�GOt4PENSATI-Ofl--INSURA"SCE :ON-FItE-WITH SJLHD? YES " 0' <br /> TYPE OF WORK (Check) : NEW WELLM,, DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ nN. <br /> WELL CHLORINATION ❑ WELL •ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ RUMP REPAIR[]._ RUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK ,50 S.EWER LINES def PIT PRIVY <br /> SEWAGE DISPOSAL 'FIELD CESSP OL/SEEPAGE PIS OTHER <br /> PROPERTY LINV PRIVA�ESTIC WELL-3-&— PUBLIC DOT�ESTIC WELL r <br /> INTENDED USE TYPE OF WELL., CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation --Ir7-11 <br /> _Domestic/private Drilled Dia. of Well Casing <br /> fd- <br /> Domestic/public62 Gauge of Casing f ,0 <, rs . , <br /> Irrigation e--Gravel Pack Depth of Grout Seal <br /> Cathodic Protection L.,Rotary Type of Grout <br /> DisposalOther Other Information <br /> Geophysical Surface Seal Insta ed.b : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. <br /> PUMP REPLACEMENT: ❑State Work Done \� <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter :f A roximate Depth <br /> p p p. P <br /> Describe MateriaT and Proce ure <br /> I "hereby certify that I have prepared this application and that the work will be done in accordant <br /> Frith San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <br />'iealth District. Home owner or licensed -agent's signature certifies the following: <br /> "I certify that in the performance of the -work-for which th-iss. 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 /> E WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> D PL T L N--ON REVERSE SIDE) : <br /> > <br />'HASE I y v_= R DEP RTM USE JONLY .t - <br /> PPL-I TION ACCEPTED BY - ., 7/9DATE X-� <br /> 0DITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTIONPHASE III -FINAL INSp CTION <br /> NSPECTION 8Y DATE _INSPECTION BY DATE <br />'H 14 26 Rev. 9/78 9/78 . 2M <br />