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SAN JOAQUIN LOCAL HEALTH DISTRICT — - <br /> MFOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. XW_ <br /> a73- <br /> Telephone: (209) 466-6781 <br /> r � Date Issued 3 ag 79 <br /> k APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> -(Complete In Triplicate) <br /> q 1. <br /> Application is hereby made to the San Joaquin Local. Health District° fora permit to construct <br /> E ,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 . N <br /> 'CITY/TOWN_�.�,,���,�f <br /> ` 'Owner's Name U 14e` i,;A4 ,4 �"o/ Phone <br /> Address a City <br /> Contractor's Name jZr . .?f License Phone <br /> IS .CERTIFICATE `OF WORKMAN'S COMPENSATION INSUR 610E ON FILE WITH SJLHD? YES � 0 <br /> TYPE OF -WORK (Check) : NEW,WELLU;�-'DEEPEN ❑ RECONDITION DESTRUCTION Ej <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER❑ s <br /> PUMP .INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> - cy <br /> DISTANCE.TO 'NEAREST: SEPTIC TANK S,0g, SEWER LINES S . .PIT PRIVY <br /> SEWAGE DISPOSAL".,FIELD . •— SSPO L/SEEPAGE PIT OTHER <br /> PROPERTY LIN B'i RIVATE DOMESTIC WELL— PUBLIC DOMESTIC WELL r <br /> INTENDED USE TYPE OF WELL SPEC IFI.CATIONS � �r <br /> Industrial 1�abl—Tool'! Di-a: -of Wei -Excavation lwe-4L <br /> Domestic/private L-Bri11ed Dia. of We11 :Casing Z <br /> Domestic/public Driven, Gauge.:of-4Casing .f <br /> Irrigation vGravei, Pack. Depth of Grout Sea ,� F <br /> - _ Cathodic Protection �--I ary Typi_of.rGr--out _ <br /> - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor is <br /> Type of Pump .` . V 0000 ----- ` H• ,,_. . <br /> PUMP 'REPLACEMENT: ' State Work Done' „ - - <br /> PUMP. REPAIR:- _"__QState Work Done' <br /> DESTRUCTION °OF WELL: Well Diameter Approximate Depth <br /> Describe Material and ProceduFe <br /> I hereby ,certify that I havejprepared this applicationtand that the work will be done in accordan a <br /> with San ,Joaquin County Ordinances , State.,Laws, and Rules and Regulations of -the- San Joaquin Local <br /> Health District. Home owner or licensed agen't' 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 An `such manner as to 'become subj'e'ct-to Workman's Compensation <br /> laws of California. <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND AI AL INSPECTION. <br /> f SIGNED !TITLE: DATE: <br /> MFOR <br /> P N ON REV LSI:,E= <br /> EPARTMENT USE ONLY <br /> PHAS E 'ID <br /> Q� <br /> APP41CATLON ACCEPTED BY y, DATE <br /> ADDITIONAL "COMMENTS: `T' �,. <br /> PHASE II GROUT INSPECTION MASE III FINAL iNSPECR N <br /> INSPECTION BY DATE INSPECTION BY fA� ' DATE <br /> SEH 14 .26 Rev. 9/78 N• t _ `9/78 2M <br />