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CO d SAN JOAQUIN LOCAL HEALTH DISTRICT <br />--FOR--OFFICE USE: '1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.Z - a y3LJ <br /> a <br />- Telephone: (-209) 466-6781 <br /> Date Tssued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT r <br /> ThJs Permit Ex ires .l Year F-rom 'Date Issued ' <br /> (' Complete In Triplicate <br /> Application is hereby made tolthe San Joaquin Local Health District fora permitto construct ' <br />.and/or install the work herei•h described. This application is made- in compliance with San <br /> 1'oaqui n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS <br /> CITY/TOWN C-1 � <br /> Owner' s Name t.- ` Phone___r_____ <br /> City . <br /> Address _ - <br /> Contractor' s Name License#.'/ hane <br /> IS CERTIFICATE OF WORKMAN'S rnMPr TTO1N INSURANCE ON FILE WITH SJLHD? YES NO' <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION [ DESTRUCTION( <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER <br /> PUMP INSTALLATION ❑ PUMP REPAIR F�D PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY u1 <br /> SEWAGE DISPOSAL FIELD CES—SPU-OL/SEEPAGE PIT OTHER <br />` PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private _77 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 i ' Other Other Information <br /> _ <br /> Geophysical , 1Surface Seal Installed by: <br /> ` PUMP INSTALLATION: Contractor - <br /> H.P. Z) <br /> Type of Pump <br /> i 'PUMP REPLACEMENT: F]State Work Done <br /> PUMP REPAIR: (State Work Done -Q� <br /> r , A roximate Depth <br /> `.' DESTRUCTION OF WELL: Well Diameter pp <br /> Describe Materia an Procedure <br /> I hereby certify .that I havelprepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home ownerlor 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." j <br /> : l WILL CALL FOR A GROUT INSPECT P IOR- GROUTING AND A FINAL INSPECTION. <br /> SIGNED LE: DATE: k <br /> T PL N N REVERSE SIDE <br /> t OR DEPA.TME T USE ONLY <br /> PHASE I DATE Z9 <br /> ,APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: I� <br /> PHASE II GROUTINSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY `DATE INSPECTION BY \ N� _ DATE <br /> j <br /> Fu 1A'99 -Ro., 19-77 1/78 2M, <br />