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SAN JUAQUIN LUUAL HLALIH UISIRIU <br /> _- OFFICE USE: 1601 F Hazelton Ave. , Stockton, CA 9r 'S Perm tNo. yZ_ lis <br /> Telephone: (209) 466-6781 `.J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ �7 <br /> This Permit Expires I Year From Date Issued <br /> Complete In Triplicate <br /> Iication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> L/or install the work herein described. This application is made in compliance with San <br /> )an--,in County Ordinance 1,o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> (..► T STREET ADDRESS - � � •_/ ��� £� _ -� � CITY/TOWN y <br /> rner's NameZZ _ jF <br /> F % Phone ; <br /> cess <br /> )ntractor's Name Licens_ff O Phone1 - 2 `�`�y <br /> CERTIFICATE OF WORKMAN'S COMIPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> SPE OF WORK (Check) : NEW WELL C} DEEPEN 0 RECONDITION ❑ DESTRUCTIONE] <br /> WELL CHLORINATION 0 WELL ABANDONMENTED OTHER 0 <br /> PUMP INSTALLATION [J-----VUMP REPAIR❑ PUMP REPLACEMENT El <br /> I TANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> �.. SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 /> 4_--Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> y� Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _ <br /> Disposal t er Other Information <br /> }_ Geophysical urface Se Installed by: <br /> IJMP INSTALLATION: Contract r _jr1_1c, <br /> Type of Pump H.P <br /> l'4"P REPLACEMENT: ❑State Work Done <br /> f:'""P REPAIR: ❑State Work Done <br /> t�.TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Hereby certify that I have prepared this application and that the work will be done in accordan, <br /> ith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca• <br /> lth 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 1 <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of ifornia. " , ? <br /> FILL CAL F- R A GR UT INSPE /'PRIG 'TO GROUTING AND iNAL INSPECTION. <br /> I GNED TITLE• DATt: <br /> (DRAW PLOT PLAN ON RE E IDE <br /> FORDEPARTMENT,>JSE ONLY <br /> RASE 1 <br /> "'LICATION ACCEPTED BY �ti•�. A&I � DATE A 7� <br /> )ITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> °"PECTION BY DATE INSPECTION BYE. % DATE G,-/� <br /> %.J � <br /> ; <br /> H 1426 Rav- 19-77 1 /78 2M <br />