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N JOAQUIN LOCAL HEALTH DISTRIC <br /> FOR FFIC S E . Hazelton Ave . , Stockton , CA 95205 Permit No . <br /> fin <br /> Telephone: ( 209 ) 466 -6781 I If Wo I <br /> Date Issued <br /> APPLI N FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> 3 1979i ( Complete In Triplicate ) <br /> loplication <br /> the San Joaquin Local Health District for a permit to construct <br /> ind/ or instal �� n described . This application is made in compliance with San <br /> Joaquin County Ordinance Not 1862 and the Rules and Regulations of the San Joaquin Local _ Health <br /> ) is tri ct . <br /> : XACT STREET ADDRESS CITY/TOWN <br /> )wner ' s Name - A4^ Phone!_ _ <br /> Iddress- B I� u ( _ City <br /> ;ontractor ' s Name _ <br /> License# l � 3 7lQ Phone <br /> IS CERTIFICATE OF WORKMAN ' SICO ENS TION INSURAt10E ON FILE WITH SJLHD ? YES 0 <br /> 'YPE OF WORK ( Check ) : NEW WELL ❑ DEEPEN ❑ RECONDITION Q DESTRUCTION1] <br /> WELL'! CHLORINATION0 WELL ABANDONMENTZCl OTHER 0 <br /> PUMPINSTALLATION 1;9 PUMP REPAIR ❑ PUMP REPLACEMENT Q <br /> ) ISTANCE TO NEAREST : SEPTIC TANK - SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/ SEEPAGE PIT OTHER <br />' PROPERTY LINE - PRIVATE lllDl�F1ESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial * ' Cable Tool"" Dia . of Well Excavation C <br /> Domestic / private ;W Drilled Dia . of Well Casing <br /> Domestic/ public Driven L Gauge of Casing <br /> Irrigation II 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 /> 'UMP INSTALLATION : Contractor <br /> Type of Pump H . P . <br /> ?UMP REPLACEMENT : ❑ State Work Done <br /> 'UMP RFdPlA+R-: � S�tate . Work Done .. z 6 <br /> )ESTRUCTION OF WELL : Welli' DiameteI A roximate Depth <br /> Describe Material and Procedure <br /> a. <br /> I hereby certify that I have prepared this application and that the work will be done in accord <br /> gith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loi <br /> iealth District . Home owneir 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 /> I WILL CALL FORA GROUT INS1' E ON P IOR TO GR_ UTING AND A ,FINAL INSPECTION . <br /> iIGNE ' TLE': rf DATE : <br /> aliFvc rr lAADR PL T PL ON REVERSE SIDE <br /> ' <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I ^_ <br /> 41PLIIATIO1 ACCEPTED BY DATE <br /> flDDITIONAL COMMENTS : <br /> PHASE II GRO['zINSPECTION PHASE III NAL JW14k�DN <br /> INSPECTION By pjDATE" lll`"" "" INSPECTION B <br /> a 14 26 Rev . 9/ 78 <br />