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SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephoner (20.9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued /J ;7 <br /> -(Complete In TriplYcae) ` <br /> Application is hereby made tolthe San Joaquin Local Health- 'District for a permit to construct <br /> 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 CITY/TOWN <br /> Owner's Nam- <br /> Jr tz Phone <br /> ;Address__7Z,2 d 2 - Ci ty <br /> Contractor's Name License Phone kfe <br /> -� <br /> IS CERTIFICATE OF WORKMAN'S''CTIPENSATION iN5URA"E ON FILE-WITH SJLHD? y YES 0 <br /> TYPE OF WORK (Check) : NEW WELLVQ DEEPEN ❑ RECONDITION [2 DESTRUCTION *� <br /> r` . WELL: CHLORINATION Q WELL ABANDONMENT Q OTHER 0 <br /> t .PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT 0 <br />(DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES/�f� PIT PRIVY -� .• <br /> SEWAGE DISPOSAL f FIELDS CESSPOOL./SE PAGE PIT OTHER-�-- <br /> f f ;f PROPERTY LINV44PRIVATE DOMESTIC WELL: PUBLIC DOMESTIC WELL j <br /> INTENDED. USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial F` •—_ Cable Tool Dia. of Well Excavation ILI 11 <br /> Domestic/private Drilled <br /> . . Dia. of Well Casing <br /> Domestic/publ i c Driven Gauge of Casing-- �� �,�� �� <br /> (—Irrigation` Gravel Pack Depth of Grout Seal UJ �` <br /> _Cathodic Protection Rotary Type of Grout , <br />_moi isposal Other Other Information " - f <br /> Geophysical Surface Seal Installed Ey-: <br />-PUMP <br /> :PUMP INSTALLATION: Contractor <br /> f <br /> { d Type of Pump H, , <br />'PUMP 'REPLACEMENT: State Work Done Y <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an .Proce ure <br /> - i <br /> I hereby'mcertify that Chave prepared this application and that the work will be done in accordance <br /> With San J'oaQuinCaunty 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 mwhiCh 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 /> I WILL-CALL FOR A 'GROU INS CT GROUTING AND A""FINAL INSPECTION.- <br /> SIGNED i <br /> TITLE: a kv DATE: nc <br /> PLOT TLVON REVERSE E ` , <br /> CHASE I I MR DEPARTNE—NT USE ONLYr . <br /> PPLICATION ACCEPTED BY [ DATE ?9 i <br /> kDDITIONAL COMMENTS : ; + <br /> ' PH E II GROUT INSPECTIO <br /> NSPECTION BY PHASE III FINAL INSPECTION <br /> DATE INSPECTION BY DATE 3 t <br />:H 14 26 'Rev. /7$ - UAL <br /> Q/79 9M <br />