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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L FfICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issuedzzl <br /> !s' <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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_aad�-tom Rut n -lations of the San Joaquin Local Health <br /> District. IG ,�� y <br /> EXACT STREET ADDRESS e�ct/t J " �� <br /> CITY/TOWN <br /> Owner's110S'SnA-,,- <br /> -_ Phone 7� <br /> Add res.s n2 y, <br /> C i tY7aG 7c sv j <br /> Contractor's Name i cense# 65 J6 Phone 5�6!K <br /> 1 <br /> IS CER IF-1CATE OF WORK`1AN'S COMPENSATION INSURAINCE CN FILE WITH-SJLHD? YES No <br /> .r+ <br /> TYPE OF: WORK' (Check_) : NEW WELL❑ DEEPEN D RECONDITION �J DESTRUCTION'Cj <br /> _ WELL CHLORINATION Q WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION [A-- PUMP REPAIR❑ PUMP REPLACEMENT 0 pQ <br /> DISTANCE TO NEAREST: SEPTICTANK_11-'P`j� SEWER LINES IBJ PIT PRIVY <br /> SEWAGE DISPOSI1�L IELD SS� 1' <br /> C E �L/SEEPAGE TI—T OTHER t,.l <br /> PROPERTY LINE D'PRIV E DOKESTIC WELL PUBLIC D ESTIC WELLi <br /> INTENDED USE TYPE OF WELL, ,, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Wel Excavation <br /> Domestic/private Drilled ,� Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth_of Grout Sea <br /> _____Cathodic Protection Rotary. Type of Grout <br /> Disposal Other Other Information :- <br /> Geophysical Surface Seal-Insta ed y: <br /> PUMP INSTALLATION: Contractor ✓111&-trlr,9 U r,7L <br /> f Type of Pump cn <br /> PUMP REPLACEMENT: [:]State Work Done <br /> PUMP REPAIR: C}State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ <br /> - -Approximate Depth 1 <br /> Describe Materia an Proce ure j <br /> I hereby certify that I have prepared this application and that the work will be doneinaccordance <br /> with Sad 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: t y <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ an <br /> p Y y person in such manner as to become subject to Workman s Compensation <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND INAL INSPECTION. 1 f <br /> ;IGNED �� ~ TITLE: '' DATE:��'. <br /> 41 <br /> DR W P T L ON REVS E S E -�—,f <br /> >HGcF I <br /> ' FO DEP R 'T USE ON <br /> �) C['ION ACCEPTED BY DATE i„� <br /> ,D:,1 IONAL COMMENTS: <br /> PHASE Ii GR UT INSPECTION <br /> NSPECTION BY PHASE III INAL INSPECTION' ; <br /> DATE INSPECTION BY DATE <br /> N 14 26 Rev. 9/78 <br />