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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> =FOROFFICE USE: 1601 E. Hazelton- Ave. , Stockton, CA 95205 Permit No. ,�q-low <br /> Telephone: (209) 466-6781 <br /> 1.1 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued a -S-79 <br /> This Permit Ex ires 1 Year From Date Issued <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 HealtA <br /> District. <br /> EXACT STREET ADDRESS ./ '12 /1,! ftp CITY/TOWN <br /> Owner's Name j/ 4LEIC Phone <br /> Address f I G %� '. i1 N 1�I7 . City , %C1�/r'TO 1/ <br /> Contractor's Name ,1) �Jj' }Wry L_ - [C =I�?6B/A/,ri cense# /,Z-0 Phone <br /> -IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Chec,k) :_NEW WELLM DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q- "WELL ABANDONMENT OTHER <br />' �-i- PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT [ �, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DTSPOSAL -FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL T CONSTRUCTION SPECIFICATIONS <br /> Industrial; Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing ` <br /> Domestic/public Driven _� Gauge of Casing <br /> Irrigation Gravel Pack' Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout T <br /> Disposal Other Other Information <br /> Geophysical Surface Sea1 •-Instal ed by: <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 <br /> Describe Materia an Procedure <br /> I } <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 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. " r <br /> I WILL CALL FOR A GROUT INSP CTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: , DATE:�� - <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY '09- DATE g' 7 <br /> ADDITIONAL COMMENTS: <br /> P E I ROUT INSPECTION PHASE F L INSPECTION <br />' INSPECTION B DATE _JS_7 INSPECTION BY ATE <br /> I Fly 1a99 nok! 19_77 - 1 /7R 9M <br />