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i <br /> SAN JOAQUIN LOCAL% HEALTH DISTRICT. <br /> EOR FFICE USE.: 1601 t�Hazelton Ave. , Stoccton, CA 5 Permit No. <br /> r ..fTelep6one: (209) 466-6:781' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - 3-,2 <br /> This Permit,Exi,res J. Yea,rjrom ,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 ap'p°licatfon is made in compliance with .San <br /> .'oanuin County'Crdinance� No -186:,,a6 the Rules and Regulations of the San Joaquin, Local- Health <br /> str�ct. <br /> 4 EXACT STREET, ADDRESS, <br /> CITY/TOWN <br /> Owner's Name Phone !24> <br /> , //) <br />! Address . . , <br /> y <br /> Contractor's Name 0—*t7' J-779 N'License c9-/'3 Phon <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO1,11 INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION E3 <br /> WELL -CHLORINATION 0 WELL ABANDONMENT 0 OTHER❑ � <br /> PUMP INSTALLATION Wr' PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: , S-EPTIC. TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> 1 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable 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 Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information R <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> T <br /> PUMP REPAIR: EKtate Work Don <br />' I)ESTRUCTION:4FWELL: Well Diameter Approximate Depth <br /> r Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accorda^n{ <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 CALL FOR A GROUT INSPECTION PRIOR TO .GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: �n�A _ DATE: <br /> r <br /> (DRAW PHOT PLN ON REVER5E IDE <br /> FOR DEP RTMENT US ONLY <br />( PHASE I <br /> APPLICATION ACCEPTED BY DATE <br />' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION V PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> =U 7 A'),r- 17—.. I4 '77 9 /-70 77„i <br /> e r <br />