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(1 N JOAQUIN LOCAL HEALTH DISTRIC- <br /> FFICE USE: 160 1 Hazelton Ave. , Stockton, CA ns205 Permit No. 7 9-,16 2 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -a -�9 <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 996G CITY/TOWN <br /> t.. / <br /> Owner's Name ,, /A -r c2 j-,4' ' Phone <br /> Address _cam_ :&4 city ice,,,: L �r . . ✓� <br /> Contractor's Name License# /!a 7) Phone 4/ 1 —79 7 <br /> IS CERTIFICATE OF WORKMAN'S CO""P N&TION INSURANCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION E2 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT O OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ® m <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER ,` <br /> IC <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 <br /> _Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - „ �y. _, /�,, �iri1 H.P. <br /> PUMP REPLACEMENT: [0 State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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. <br /> I WILL C LL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE k Zr. TITLE: ( DATE: <br /> D LON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I z <br /> APPLI IMON ACCEPTED BY �' . ,� r, � �� DATE J Z <br /> ADDITIONAL COMMENTS: c <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 4--21-79h <br />