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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. �-,3 5.7 <br /> Telephone: (209) 466-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> k <br /> (tomplete .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 <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> i <br /> .EXACT STREET ADDRESS N S � /�a�'h j 1,11der e m e CITY/TOWN .S7PiC�CTO/� } <br /> Owner's Name ,41 i ,PlG Phone ?- <br /> Address <br /> �2 Zeed City S ae a <br /> Contractor's Namefati tae License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES <br /> TYPE OF`WORK (Check) : NEW WELL L DEEPEN ❑ RECONDITION [ DESTRUCTION( L4 <br /> WELL CHLORINATION 0 WELL ABANDONMENT ® OTHER 0 � <br /> x PUMP INSTALLATION El PUMP REPAIR❑ PUMP REPLACEMENT [3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY l <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC D1MESTIC ITE <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 Sea <br /> Cathodic Protection . Rotary Type of` Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 1411, Approximate Depth O = i <br /> Describe Materi a and Procedure v- tic e. w, ,4 - <br /> �rP G <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> jwith 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'so-Compensation <br /> laws of California." 4 <br /> I WILL CAL FOR A GRO INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />(SIGNED TITLE: , DATE: -4112177 <br /> DR W PL L N ON REVERSE SIDE <br /> PHASE I MR DEPARTMENT USE ONLY <br /> PPPLICATION ACCEPTED BY DATE A1117179 <br /> ADDITIONAL COMMENTS: <br /> *PHAS11 GROUT INSPECTION PHA II ' NAL INSPECTION <br /> :INSPECTION BY DATE___ !L?0-2r ' INSPECTION DATE L/-AP <br /> EH 14 26 Rev. T` 9/78 32 — <br />