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SAN JOAQUIN LOCAL HEALTH DISTRICT �---. <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. lq -66 ) <br /> Telephone: , (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 6-zt-l4 _ <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is -made in compliance with San 1 <br /> Joaquin County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET A DRESS f S �• �� CITY/TOWN /S <br /> Owner's Name Y 1 j' �` TS Phone <br /> Address % X �_ �GCity <br /> Contractor's Name eo S S _ License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE- WITH SJLHD? YES___4--"_ No <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION { DESTRUCTION[n <br /> LORI <br /> WELL CHNATION WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR 0 PUMP REPLACEMENT 0 18 <br /> DISTANCE TO NEAREST: SEPTIC TANK/19W SEWER LINES d PIT PRIVY <br /> SEWAGE DISPOSALF�IELD CES�L/SEEPAGE PIT ETHER r <br /> PROPERTY LIN 'PRIVATE DOMESTIC WELL PUBLIC DOMESTIC. WELL. — <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria /able Tool Dia. of Well Excavation 'Ve-,4 <br /> Domestic/privateyDri11ed Dia. of Well Casing �Gz <br /> Domestic/public Driven Gauge of Casing ze9 ac <br /> �v Irrigation Gravel Pack Depth of Grout Sea '" <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> /777 <br /> Geophysical Surface Seal Installed b : <br /> PUMP INSTALLATION: Contractor '11�11eplwew f s <br /> Type of Pump <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP 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 accordance <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 such manner as to become subject to Workman's Compensation <br /> laws of California." <br />. I WILL CALL FOR GROUT INSPECTION PRIOR TO GROUTING AND A F NAL INSPECTION. <br /> SIGNED TITLE: DATE: Z <br /> PLTT_P_LV ON REVERS SIDE) <br /> r <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLI ATION ACCEPTED BY L�n� DATE b 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE /L7,?' INSPECTION BY DAT 7 <br /> EH 14 26 Rev. 9/78' <br /> '9/78 -_'2M <br />