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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave, , Stockton, CA 95205 Permit <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Hate Issued <br /> (Complete In Triplicate) MA ) <br /> L <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. W / <br /> EXACT STREET ADDRESS "; IV 0 P- j (ZG CITY/TOWN a-SCAtO ►J <br /> Owner's Name : LR U C-rr, p 7 Phone53'38--r �'g �_ ,_ <br /> Address a1 D S 2 City <br /> Contractor' s Name 0-TT0 G-ft S (1F7'License# Phone_ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES go <br /> TYPE OF WORK (Check) : NEW WELL. DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION M PUMP REPAIR❑, PUMP REPLACEMENT [ N <br /> DISTANCE TO NEAREST: SEPTIC TANK 6� SEWER Li�dES PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSP OL/SEEPAGE PIS OTHER <br /> PROPERTY LINE - PRIVAT�ESTIC WELL PUBLIC DOMESTIC WE—LL — <br /> INTENDED USE TYPE OF WELL.. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool } Dia. of Well Excavation " <br /> —Domestic/private Drilled Dia -of-Wei-1-Casing r <br /> Domestic/public _Driven Gauge of Casing ' <br /> _Irrigation Gravel Pack Depth of Grout Se .t <br /> Cathodic Protection Rotary y Type of Grout <br /> Disposal Other - Other Information <br /> „Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H,P. <br /> .PUMP REPLACEMENT: ❑State Work Done ,, <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL:- Well Diameter Approximate Depth Y <br /> Describe Materia an 'Procedure <br /> .I hereby certify that I have prepared this application and that the work will be done in accordant, <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District, dome 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 /> WILL C LL R A GROUT PECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: Q DATE: t� 7 <br /> DR W PLO PLTN ON REVERSE SIDE <br />�HASE I FOR DEPARTMENT USE ONLY <br /> TP LIGATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - .. <br /> PHASE II GROUTINSPECTION 4 PHAS AL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3 ve/7,f <br /> EH 14 26 Rev. 9/78 - - - "r/o �,�. C74E-Ir. t 9/78 CX,, <br />