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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICEFOR USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (fomp l ete .i n Triplicate), !g - <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 and the Rules and Regulations of the San Joaquin Local Health <br /> District. ,/�77? s • k.,­uLj''" DAe-,O. <br /> EXACT STREET ADDRESS t= } '' �` `�' ' " CITY/TOWN A 4' - <br /> Owner's Name t�Ia7Phone <br /> Address ; . k City <br /> Contractor' s Name � : '' License# 0 Phone <br /> IS CERTIFICATE OF WORKMAN'S CO11PENSATION INSURA"dCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORKC (Check) : NEW WELLDEEPEN C7 RECONDITION DESTRUCTION[ <br /> qw . WELL CHLORINATION C1 WELL ABANDONMENT 0 OTHER F <br /> PUMP INSTALLATION Q PUMP REPAIR 0 PUMP REPLACEMENT C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r .. PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Dr. ill ed Dia. of Well Casing f " <br /> Domestic/public Driven Gauge of Casing ' <br /> Irrigation Gravel Pack Depth of Grout Sea /0- &i <br /> Cathodic Protection �'` Rotary Type of Grout " <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ]State Work Done— <br /> PUMP <br /> onePUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> . I hereby certify that I have prepared this application and that the work will be done in accordan( <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' su.ch manner as to become subject to-Workman's Compensation <br /> ,laws of California., �A-177?7/C4, Loc. I ;-)Zre.E , <br /> I WILL CALLrFOYA GROUT ;INSPECTION PR FR TO GROUTING AND A FINAL INSPECTION. <br /> �' . � TITLE: DATE:1 ,�e,» ; <br /> SIGNED - .,. <br /> DRAW PLUT-PUNON REVERSE ME <br /> FOR D,EP RTMENT US& ONLY <br /> PA �.�L DATE <br /> CATION ACCEPTED 8 , <br /> 'ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL ' INSPECTION <br /> 'INSPECTION BY DATE INSPECTION BY . DATE <br /> ,EH 14 26 Rev. 9/78 9/78 . . 2M <br />