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1� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR_OFFICE USE: Y 1601 E. Hazelto.n..Aye. ,. Stockton, CA 95205 Permit No._,79r/1z9 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR TELL CONSTRUCTION OR PUMP PERMIT Date Issued -Y 7 <br /> This .Permit Ex fres l Year From Date Issued <br /> Complete. In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for permit <br /> .Y q o ap tto <br /> and/or install the work herein. described. This application is made in compliance with San <br />.'oaqu;n County,,Ordinance No. 1862 and . the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS g ? ` 1 L2 /"h CITY/TOWNZ- <br /> Owner' s Name <br /> G Phone <br /> Address _ City <br /> Contractor' s Name Lice sn e# Phone <br /> IS CERTIFICATE OF WORKMAN'S COP•MPENSATIO"i INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITIONN [QDES DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION W PUMP REPAIR❑ PUMP REPLACEMENT ❑ � : <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY {�{ . <br /> SEWAGE ;DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER W <br /> • 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 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP- IN51-ALLATION: Contractor 5elr <br /> Type `of PumpC/4e H.P. <br /> PUMP_!REPLACEMENT: M State Work Done i <br /> PUW-R PAIR: -- ❑State Work Done <br /> DESTRUCTION OF WELL We:l1Diameter _ •' ___.-:....._ T---. ,Approximate,Depth_,.,i�7 0� -. <br /> Descr;ibe--Ira teria and Procedure <br /> b ! <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> Frith San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local ; <br /> lealth District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that' in the performance of the_..wo.r_k. for which 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 Cal ifornfa:'" f, <br /> I WILL CALL FOR GROUT INSPECTION FPRI TO GROUTING UD A_ FINAL INSPECTION. <br /> iIGNED TITLE: � � DATE: <br /> (DRAW, PLOT PLTN- ON REVERSE SIDE) <br /> ,FOR DEPARTMENT USE ONLY <br />'HASE I 'r <br /> FPPL I CATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> PHASE LII FINAL INSPECTION � <br /> NSPECTION BY DATE INSPECTION BY DATE /-- <br />.H 1426 Rev 12-77 rl-I-A M <br />