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` SAN JOAQUIN LOCAL HEALTH DISTRIC, <br /> FFICE USE; 1607' Hazelton Ave. , Stockton, CA (I-%n5 Permit No. 79 -76 <br /> Telephone: (209) 466-6781 <br /> ' S <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (,Complete In-Triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District to nstroct <br /> ! nd/or install the work herein described.. This application is made in comp Bance wi San <br /> (c <br /> oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> istr�ict. <br /> XACT STREET ADDRESS V t7 <br /> i S CITY/TOWN_ <br /> wner,'s Name Phone .� <br /> ddre''ss <br /> City <br /> Dntractor's Name Al vL—S Licensees Phone 5� <br /> a <br /> S CERTIFICATE OF WOR MAN'S CO111PENSATION INSURANCE ON FILE WITH SJLHD? YE <br /> f� <br /> S � <br /> fPE OF WORK (Check) : 'NEW WELL C] DEEPEN ❑ RECONDITION (,y'1 DESTRUCTIONJ� <br /> WELL CHLORINATION Q WELL ABANDONMENT p OTHER 0 <br /> ;i PUMP INSTALLATION 0 PUMP REPAIR a- PUMP REPLACEMENT Q c4 <br /> :STANCE TO NEAREST: - SEPTIC TANK SEWER tINE5 PIT PRIVY I <br /> SEWAGE DISP SAL IELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTI <br /> C WELL PUBLIC DOMESTIC WELL <br /> _ <br /> fINTENDED USE TYPE OF WELL.Industrial _ CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> EL Domestic/private Drilled Dia. of Well Casing <br /> ,bDomestic/public -Driven <br /> Gauge of Casing <br /> �I Irrigation Gravel Pack Depth of Grout Sea <br /> ilCathodic_ Protectlon Rotary Type of Grout <br /> I Disposal Other Other Information <br /> ! Geophysical Surface Seal Installed <br /> MP INSTALLATION: Contractor <br /> Type of Pump <br /> N.P. <br /> MP REPLACEMENT: <br />� ❑State Work Done <br /> '1P REPAIR: 5n State Work Done <br /> STRUCTION OF WELL: Well Diameter <br /> Describe Material and Rrocedure Approximate Depth <br /> hereby certify that I have prepared this application and that the work will be done in accordant <br /> th San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San. Joaquin Local <br /> ilth .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 shalI <br /> not employ any person in such manner as to become subject to Workman 's Compensation <br /> 'laws of California. "., , <br /> BILL CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> ;NED TITLE: <br /> i. DR W PL P N ON REVERSE DE DATE: v� <br /> ISE III OR EP TMENT ONLY <br /> 'LI_CA TI0N ACCEPTED BY <br /> IITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION /11 <br /> PECTI8Y � PHASE II L IN <br /> FINASPE TION <br /> �ON � " <br /> 1� DATE INSPECTION BY <br /> 14 26 Rev. 9/78 -�r° DAT I <br /> �) ' <br /> 9/7w 2M <br />