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JOAQUIN LOCAL HEALTH DISTRIC ----. <br /> EQR-OFFICE USE: 1601 aazelton Ave. , Stockton, CA 5 Permit No. 75Z, 3.,3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued /-f- 7 <br /> (Comp I ete I n- Tri pl i cate). <br /> Application is hereby made to the San Joaquin' .Local Health District for a permit 1:6-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 %l - IIr CITY/TOWN; �vL=�Car� <br /> Owner's Name Phone 9e <br /> Address _<Z6 ftlr City.- .0 .a <br /> Contractor's NameLicense Phone ,-� .:/n <br /> IS CERTIFICATE -OF WORKMAN'S C011-4PENSATION INSURANCE N FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL O DEEPEN RF RECONDITION DESTRUCTION <br /> 'WELL CHLORINATION p WELL ABANDONMENT ® OTHER 0 � <br /> PUMP INSTALLATION [I - PUMP REPAIR p PUMP REPLACEMENT [] W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' PIT PRIVY --- <br /> SEWAGE DISPOSALTIELDQ�.� CESSP L/SEEP�4GE PIT OTHER <br /> PROPERTY LINi'6 4PRIVATE DOMESTIC WELL_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. <br /> Industrial _Cable Tool Dia. of We Excavation jR <br /> x Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publicDriven. Gauge of :r 2 Casing . . __.&AA)f ] <br /> Irrigation' Gravel Pack Depth of Grout Sea <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.P. <br /> PUMP REPLACEMENT: ❑State Work 'Done _ <br /> PUMP REPAIR: (]State Work Done <br /> DESTRUCTION OF. WELL: Well DiameterApproximate Depth <br /> Describe Materia an Proce ure <br /> I hereby- certify that I have' prepared this application and that the work will be done- in accordan& <br /> gith'San .Joaquin County Ordinances, State Laws, and Rules and Regulations- of the- Sen Joaquin Local <br /> lealth D:istr'ict. 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 Califor' nia.11. <br /> [ WILL .0 F'OR , GRO T ISP TION PRIOR TO GROUTING AND A_FINAL INSPECTION. <br /> >IGNED . TITLE: E DATE: <br /> D W PL T PETN_ ON REVERS IDE <br /> 'RASE I OR DEPARTMENT USE ONLY <br /> IPPLICATION ACCEPTED BY. DATE L IM <br /> 1DDITIONAL' GOMMENTS: <br /> PHASE II GROUT INSPECTION .1 PHASE ' III FINAL INSPECTION <br /> NSPECTION BY A DATE INSPECTION BY DATE <br /> .H 14 26 Rev. 9/78 <br />