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FFICE USE• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton,.,CA 95205 Permit No.�� <br /> Telephone: (209) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR% PUMP PERMIT Date Issued <br /> ;• <br /> 7,4-7 111 <br /> G 4 (i;ompleteIn. Triplicate) 1 - w � ' <br /> d �d aG,r 2�cl�.; <br /> Application is hereby made to the San Joaquin Local Health District for a rM t tt con <br /> and/or install the work herein described. .. This application made in cam fiance with Strutt <br /> Joaquin County Ordinance No.!`+1862 and the Rules and' Regulations af.,the SanpJoaq in LocalHealthDistrict. <br /> EXACT, STREET ADD ESS <br /> Owner's Name 1 j <br /> ✓ CITY/TOWN' - - <br /> Address � i) �.� <br /> •� Phon <br /> Co ntractor's` Name City <br /> y /"c� License7Phone <br /> IS CERTIFICATE `OF.WORK'MAN S COF4PENSATIOPI INSURAINCE"ON FILE`WITH SJLHD? YES v 0 <br /> - <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN O "RECONDITION® DESTRUCTION 0 <br /> r a. WELL CHLORINATION-0 WELL ABANDONMENT Q OTHER 0 " + <br /> PUMP ;INSTALLATION [�� PUMP REPAIR-0- PIMP REPLACEMENT y' k <br /> DISTANCE TO 'NEAREST: SEPTIC TANK o SEWER�LINES PIT PRIVY <br /> - ry SEWAGE DISPOSAL IELD CESSP OL/SEEPAGE PI�T ` OTHER <br /> PROPERTY LINE - PRIVATE DO ESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE... n TYPE OF.-WELL, <br /> : r Industrial —___Viable Tool CONSTRUCTION SPECIFICATIONS <br /> L _ Domestic/private Dia. ot,We- 1 Excavation <br /> Drilled Dia-.r�of Well' Casing, <br /> — ;_Dome.sti.c/publ i c •� � Driven <br /> _ _Irrlgation -� Gauge of Casing <br /> Gravel Pack Depth of Grout Seay T <br /> athodic Protection ��Rotar $ <br /> _Disposal Otterype of Grout <br /> �, Geophysical Other Information R _ <br /> PUMP INSTALLATION; ContractortiSurface Seal Installed b <br /> Type of Pump <br /> PUMP REPLACEMENT: —H.P. <br /> mate Work Don <br />'PUMP REPAIR:TM4 ❑State Work Done <br /> DESTRUCTION OF WELLS We Diameter - <br /> Describe Mate'Vildl and Procedure Approximate Depth <br /> I hereby certify that I have prepared this application and that the work will <br /> be donin , <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations of. the Sane <br /> JoaquinoLocali <br /> qealth .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 o an <br /> p Y y person in such manner as to become subject to Workman's Compensation <br /> laws of California. ". <br /> WILL CALL FOR AGROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE: DATE: 3 �=I9`. <br /> D W PL T I N ON REVERS `SIDE <br /> HASE I FUK DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY ' ... <br /> DDITIONAL COMMENTS: DATE !-Z -77 <br /> PHASE II GROUT INSPECTION <br /> JSPECTION BYDRTE 8 PHASE . FIN L INSPECTION <br /> f 14 26 Rev. 9/78 INSPECTION BY DATE <br />