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SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> =FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA '952015 Permit <br /> Telephone: (209) 466-6781 <br /> tlti <br /> APPLICATION FOR WELL _.CONSTRUCTION OR PUMP PERMIT Date Issued�/_ie--7 9_ _ <br /> (complete In Triplicate) ;A <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 /> EXACT STREET ADDRESSf F CITY/TOWN J&j, <br /> Owner's Name Phone - <br /> Address /S Ci ty_ <br /> Contractor' s Name License#I U7,3 Phone ,/, LZ s <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES <br /> # TYPE OF WORK (Check) : 'NEW WELL 0 DEEPEN Q RECONDITION n DESTRUCTION[� - <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 `A <br /> PUMP INSTALLATION Q PUMP REPAIR M-- PUMP REPLACEMENT C) <br /> DISTANCE TO NEAREST: 'SEPTIC TANK SEWER LINES PIT PRIVY - <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL- - PUBLIC DOMESTIC WEWE-EE7 <br /> INTENDED USE TYPE OF -WELL., CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable To 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 Protections Rotary Type,of Grout -• <br /> Disposal Other Other Information <br /> Geophysical. z>. - Surface Seal Installed <br /> PUMP INSTALLATIM:_.. Contractor <br /> k t TyW of Pump H.P. <br /> PUMP REPLACEMENT; M State Work Done <br /> I <br /> PUMP REPAIR: _ %State, Work Done <br /> f DESTRUCT-ION= 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 accordar <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Loca <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 /> I - not employ any person in such-:manner as to become subject to Workman's Compensation - <br /> laws of California. " <br /> I WILL CALL FOR A GROUT INSPECTION,PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED _TITLE: DATE: . �9 <br /> h iDR WIPL T PL N ON REVERSE SIDE <br /> R DEP RTMENT USE ONLY <br /> ' PHASE I �. , . <br /> TP-PLICATION ACCEPTED BY m c. DATE 7 <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE ,III'FINk INSPECTION <br /> INSPECTION BY DATE. INSPECTION DAT -Z6'7 2 . <br /> EH 14 26 Rev. 9/78 . 1 9/78 .r. . -2M <br />