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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' VtICE USE: 1601 E. Hazelton Ave; , Stockton, CA 95205Permit No. �7 9_ q <br /> I <br /> Telephone: ' (209) 466-.6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued y_,3-99 <br /> Thli s Permit .Ex .i res 1 Year From Date 'Is'sued <br /> Complete In Triplicate <br /> Application is hereby made tolthe San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application .is made in compliance with San <br /> ,)oanuin County Ordinance. No. 1862 and the .Rules and Regulations of the .San Joaquin Local Health <br /> EXACT STREET ADDRESS ��� / S �.�X J ! �� <br /> _ ,� CITY/TOWN �` <br /> Owner' s Name ,a 43 'V� 6 _ Phone K?f_23 ZJ <br /> Address <br /> Contractor's Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'N INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION ❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION 2� PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> _ J <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES-0 PIT PRIVr <br /> SEWAGE DISPOSA_LS�I E L D ¢ <br /> � CESSP00L/SEEPAGE PIT SSt� OTHEi� <br /> PROPERTY LINE7V'PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL C/1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing i <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal I <br /> Cathodic Protection . - Rotary Type of Grout <br /> -Disposal d Other Other Information { <br /> Geophysical ' , Surface Seal Installed by: <br /> PUMP -INSTALLATION- %_p, - Contractor ` r <br /> Type ,-of Pump s v.S 4. H.P. <br /> PUMP REPLACEMENT: []State Work Done r <br /> PUMP REPAIR: ❑State Work Done R <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material amd Procedure <br /> I hereby certi6'that 1 .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 f <br /> laws of California. " s J <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. rr�� <br /> SIGNED TITLE: DATE:�]"r "^ <br /> DRAW PLOT L N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3-- <br /> ADDITIONAL COMMENTS : . t <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION I� <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> EH 1426` Rav 19-77 <br />