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SAN JOAQUIN LOCAL HEALTH DISTRICT ! <br /> f Stockton, CA 95205 Permit No 79 9'f <br /> -fog-OFFICE USE: 1601 E. Hazelton Ave.., <br /> Telephone: (209) 466-6781iy . <br /> � Date .Issued,S- 5- r; <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (Complete .In Triplicate) i <br /> Application is hereby made to the San Joaquin, Local Health District for a permit to construct <br /> and/or ..install the work herei-n described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and thRules and' Regulations of the San Joaquin Local -Health <br /> District. 3 <br /> EXACT STREET RES r / CITY/TOWN , <br /> Phone <br /> Owner's Nam <br /> Address ' City <br /> E Contractor's Nape - `L:icens;i Y P h o n ,5 <br /> r } <br /> IS CERTIFICATE OF WORKIZAN'S COMIPENSATION INSURANCE ON FILE WITH-SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELLLJ DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ ELL ABANDONMENT ❑ OTHER Q <br /> — _ - <br /> PUMP INSTALLATION PUMP REPAIR❑'- - PUMP REPLACEMENT 0 VJ <br /> ;DISTANCE TO NEAREST: SEPTIC TANK '` SEWER LINES PIT`PRIVY <br /> SEWAGE DISPOSAL FIELD. CESSPWL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PHR O r D MESTIC WE�L_ <br /> INTENDED USE TYPE OF.WELL-., CONSTRUCTION SPECIFICATIONS <br /> I Industrial Cable Tool "" -Dia:`of"Well Excavatlon <br /> ` c._-ftmestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel -Pack Depth of Grout Sea <br /> ' Cathodic Protection R ry ..-� ., Type of Grout <br /> 7 <br /> Disposal . h r Other Information <br /> Geophysical Su ce Seal I to ed b : <br /> PUMP INSTALLATION: Contract c <br /> Type of Pump H. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done, <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> of <br /> ' I hereby certify that I have prepared this application and that the work will be done in. accordar <br /> , with San Joaquin County Ordinances, State Laws, and Rules and Regulations:.of the San�Joaqui.n'Loca <br /> iHealth 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 /> i not empl y any person in such manner as to become subject to Workman> Compensation , <br /> laws o alifornia." <br /> )J' <br /> I WILL CA OR A:GRO SPECTION R TO ROUTING AND FINAL INSPECTION. . .� <br /> 4 !��` <br /> SIGNED C TITLE.: DATE ) 7 <br /> ;A DR L ON RE DE <br /> R _D RIME �-lISE-ONLY. . �- .�.. <br /> ' PNASE I - • - r DATE f <br /> P1�T LIC TION ACCEPTED BY <br /> If <br /> ADDITIONAL COMMENTS: ' " <br /> PHASE II GROUT SPECTIO.N-- PHASE 'Ii FINAL INSPECTION <br /> INSPECTION BY I DATE INSPECTION BY DA E G <br /> EH 14 26 Rev. 9/ml, 91 78 <br />