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SAN JOAQUIN: LOCAL HEALTH DISTRICT <br /> =FFICE : 1601 E. Hazelto O Ave. , Stockton, CA 95205 Permit No. '7 -bY/ <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 6 LIZE <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 <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. � � <br /> EXACT STREET A ESS �� CITY/TOW <br /> Owner's Name W PhonM�, 77 <br /> Address Cit <br /> Contractor' s Name License 3'7 3 phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES � NO. <br /> TYPE OF WORK (Check) : NEW WELLU5----' DEEPEN 0 RECONDITION [O DESTRUCTIONI� <br /> ` WELL CHLORINATION Q WELL ABANDONMENT Q OTHER 0 '~ <br /> PUMP INSTALLATION Il'" PUMP REPAIR❑- PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY tm <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL n <br /> INTENDED USE TYPE OF .WELL., CONSTRUCTION SPECIFJQATJONS O <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 41g _ <br /> _Cathodic Protection L---Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface_ Seal Instal-led by: <br /> PUMP INSTALLATION: Contractor C-l <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: M1,51tate Work Done U 1 <br /> PUMP REPAIR: Q State Work Done , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <br /> I hereby certify that I have prepared 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 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 A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DR W PLT L N ON REVE S SIDE) <br /> PHASE I <br /> FOR D P RIME T USE NLY <br /> TP-PLICATION ACCEPTED BY �� �,a.,., DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASEFII GROUT INSPECTION' PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY � DATE �0 <br /> EH 14 26 Re /78 9/78 2M <br />