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h+� NN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: �6011. Hazelton Ave. , Stockton , CA 95205 emit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued_ <br /> (Complete In Triplicate artion1 �3 '�� 3� <br /> /�cr'}"hRA7�gQ y F/157 F�/�J�n_z <br /> )plication is hereby made to the San Joaquin Local Health Di riot for a permit to construct <br /> +d/or install the work herein described. This application is made in compliance with San <br /> +aquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> strict. i r <br /> .ACT STREET ADDRESS I V900 CITY/TOWN 404 !1.!2 y0 <br /> m er' s Name Phone <br /> dress City <br /> ntractor' s NameF G C ' License# Phone <br /> CERTIFICATE OF WORK'1AN'S CO,",PENSATION INSURANCE ON FILE WITH SJLHD? YES 0 <br /> PE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Ej <br /> STANCE TO NEAREST: SEPTIC TANK /0,' SEWER LINEMESSRUL/SEEPAGE <br /> f' PIT PRIVY <br /> SEWAGE DISP SO AL FIELD1o�1� PTT_ OTHER <br /> JS'O 1 PROPERTY LINE - PRIVATE DOMESTIC WELL --,--' PUBLTr-DWESTIC WELL \n <br /> J <br /> INTENDED USE TYP OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 77 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ,- <br /> Irrigation Gravel Pack Depth of Grout Sea —1 <br /> Cathodic Protection Rotary Type of Groutt✓R aL C 1phA <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed <br /> 4P INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 1P REPLACEMENT: ❑ State Work Done <br /> 1P REPAIR: ❑State Work Done <br /> ;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and- Procedure <br /> ereby certify that I have prepared this application and that the work will be done in accordance <br /> h San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <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 <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> ILL CALL FORA GROUT INSPECTI N PRIOR TO GROUTING AND FINAL INSPECTION. <br /> NED TITLE: DATE: S /S <br /> DR W PLT TETN_ ON REVERSE SIDE <br /> FOR DEPARTMENT USE ON Y <br /> SE I <br /> LII TION ACCEPTED BY DATE 3 <br /> ITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> 'ECTION BY DATE INSPECTION BY DATE <br /> 14 26 Rev. 9/78 9/ <br />