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�__` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' <br /> . R_ OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ��-g6 <br /> Telephone: (-209) 46 -67 : <br /> APPLICATION FOR WELL CONSTRUCTfffl <br /> I 4IT. IV a e Issued�L� : <br /> Com 1 ete I n Trip to <br /> ( UL 131979 ods-030-0y <br /> Application is hereby made to the San Joaquin LocalHeal i tr'ct for a permit to construct <br />-and/or install the work herein described. This app Iicat <br /> Ni fiance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regul 'R OMM1 dh Joaquin Local Halt <br /> District. 'f�fp S _. C-r- s s(�,¢n%,� J` -��jic4,l� r P _ ° <br /> EXACT STREET ADDRESS CITY/TOWN '_50t'Ali 5 <br /> -Owner's Name� Z__ Phone !!ZM-161 Z _ <br /> Address PI -/0 Ci ty <br /> Contractor' s Name License#.2"/43 Phone �7-0 <br /> IS CERTIFICATE OF WORKMAN'S C0"1PENSATION INSURANCE ON FILE WITH SJLHD? YES N0 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT ED OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I V Eli <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial '__1Cab1_e Tool Dia. of Well Excavation Domestic/private Drilled Dia. of Well Casing + f <br /> Domestic/public Driven Gauge of Casingf <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information . <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor HP. <br /> Type of Pump f - . <br /> /105 <br /> PUMP REPLACEMENT: 17 State Work Done <br />` <br /> PUMP REPAIR:. -O State Work Done <br /> DESTRUCTION OF WELL: 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 accordarr, <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 /> 1 laws of California . " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> j DRAW PLOT PL N ON REVERSE SIDE <br /> OR PARTMEN USE <br /> ONLY y- <br /> PHASE I J <br /> .APPLICATION ACCEPTED BY DA <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE '" . .�_ <br /> 5/79 <br /> '[�i ?4 26 Rev. 9/78 <br /> a r - <br />