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€I SAN JOAQUIN LOCAL .HEALTH DISCRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.79-Zp,_,) <br /> Telephone: (209) 466--6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 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 /> jJoan.:Tn County Ordinance No. ;1862 and the Rules-and Regulations of the San -Joaquin Local Health <br /> District. ! _ <br /> EXACT STREET ADDRESS . �� s Ute-• CITY/TOWN <br /> Owner's Name ylel- Phone 2-3!Z =k?3 <br />! Address ]`7 d 5, : T4,1 �-�, sCity a ec a -- <br /> Contractor's Name -e License# Phone <br /> IS CERTIFICATE OF WORKMAN'S GOMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES NO <br /> nTYPE"O-F'-WORK (Check) : ` -N'EW 'WEL�❑- DEEPEN-p= -�-RfCONDITi0N-Q3 DESTRUCTION[��---�--- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Tq' PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEjDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �... <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ .� Cable Tool Dia. of Well Excavation -0 <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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br />, PUMP INSTALLATION: Contractor <br /> Type of Pump H. z <br /> PUMP REPLACEMENT: []State Work Done <br /> I <br /> PUMP` REPAIR: ❑Staite Work Done <br /> DESTRUCTION OF WELL: _ Well Diameter _ _ _ _ Approximate Depth --_ . __� <br /> du <br /> Describe Material an Procere _ <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 br licensed agent's signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is .'1-ssued, 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 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: -_ - .DATE: <br /> i DRAW PLOT�PL N ON REVERSE SIDE <br /> j FOR DEPARTMENT USE `ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEDBYAt, DATE 0-/�j —7 <br />' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSFECTION PHASE III FINAL INSPECTION <br />' INSPECTION BY DATE INSPECTION BY OFDATE <br /> Esq 1426 Rau 19-77 F 27�? <br /> IV- 8 � ► -Q",06e 4 Cyd -oma ,vr <br />