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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F�FICE USE: 1601 E. Hazelton Ave. , "'+ <br /> Stockton, CA -95205 Permit No. 79- Q <br /> Telephone: (209 . 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7-16-7 <br /> (toinplete In Triplicate) <br /> Ipplication is hereby made to the San Joaquin Local health District for a permit to construct <br /> ind/or install the work herein described. This application is made in compliance with Sari <br /> Joaquin County Ordina ce No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> ii stri ct. 'p <br /> XACT STREET ADDR <br /> ' r l CITY/TOWN':,'. <br /> weer's Name c i ,; (:'-rAV, r <br /> f?9 - <br /> ddress � . <br /> J �1' <br /> ' • Phone C i ty�' <br /> t <br /> ontractor' s Name f,_/,, , // �, ��' Licensed :.,ir"7 Phone K'rr J v f <br /> S CERTIFICATE OF WORKMAN'S COAMPENSATION INSURANCE ON FILE WITH SJLHD? YES ' <br /> NO <br /> (PE OF WORK (Check) : NEW WELL DEEPEN Q RECONDITION [ DESTRUCTIONC2 <br /> WELL CHLO INATION ❑ WELL ABANDONMENT Q OTHER❑ <br /> PUMP INSTALLATION 0 PUMP REPAIR O PUMP REPLACEMENT [� <br /> ;STANCE TO NEAREST: SEPTIC TANK/CVJe SEWER LINES -- PIT PRIVY— <br /> SEWAGE DISP SA_ FIELD% (j 'f CESSP OL/SEEPAGE PIT -�_ OTHER <br /> PROPERTY LINE -' PRIVATE MESTIC WELL` L PUBLIC DUMESTIC WELL 7—W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cab--e Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing � 11 <br /> ' —' Domestic/public XI <br /> Driven Gauge of Casing,-/_ <br /> Irrigation _Gravel Pack Depth of Grout Sea , <br /> Cathodic Protection Rotary Type of Grout r <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed b_y: <br /> 1P INSTALLATION: Contractor <br /> Type of Pump H• . <br /> IP REPLACEMENT: []State Work Done <br /> IP REPAIR: ❑State Work Done <br /> >TRUCTION OF WELL: Well Diameter <br /> Describe Material an Proce ure Approximate Depth <br /> a <br /> Hereby certify that I have prepared this application and that the work will be done In accordant, <br /> h San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <br /> Ith 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 /> ILL CALL FOR A ,GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> NED ` , : T f J ...,4--- 1 <br /> f.. TITLE : ..L DATE77 <br /> W N ON REV SE E <br /> SE I ,�; R DEPTRTMENTUSE ON , <br /> _INION ACCEPTED BY DATE <br /> [TIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> 'ECTION BY' DATE PHASE III FINAL INSPECTION <br /> IA ,,C „_.. „ ,,,,, INSPECTION BY nQTF <br />