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CoJ2 a- SAN JOAQUIN LOCAL HEALTH D!1 CRiCI <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ei 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 Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> • <br /> Owner's Name S Rhone <br /> Address c r,�_,City d' <br /> Contractor's Name #. 'eme t5g& License# tl 7_),r,'-Nonev -1674 - i <br /> IS CERTIFICATE OF WORKMAN'S COM SATIO'N INSURANCE ON FILE WITH SJLHD? YES -2S NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑' RECONDITION ® DESTRUCTION[2 <br /> WELL CHLORINATION Q WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION 0 PUMP. REPAIR RI PUMP REPLACEMENT [] <br /> o <br /> DISTANCE TO NEAREST.: SEPTIC TANK SEWER LINES PIT PRIVY °4 ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 ° <br /> Industrial Cable Tool r Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _K.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 /> k <br /> PUMP INSTALLATION: . Contractor fI <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: CI State Work Done <br /> PUMP.'REPAIR: [State Work Done J � � <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth':` :. . ' <br /> Describe Material and Proce ure <br /> I hereb certif that I have prepared this application and that the work will be done in accordance <br /> Y . Y p p <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 44 <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING F N NSPECT N. <br /> SIGNED TITLE: DATE: <br /> DRAW PLOT PL N ON - <br /> ` FOR DEP RTMENT ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -27 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE>Ul FLML INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -?�(��� <br /> Gu 1 A'31Z Do 1077 x , - —1/78 2M -� <br />