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SAN JOAQUIN .LUCAL HEAL I H DISI RIC I <br /> OFFICE USE: 1601 E. Hazelton Ave. ,. Stockton, -.CA 95205 Permit No.7f/S-9 4 <br /> Telephone: {209) 466-67.81 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP 'PERMIT Date Issuedj�L -2- g <br /> This Permit Expires 1 Year From ;Date °Iasued <br /> Complete In Triplicate <br />', Application is hereby made to the San Joaquin. Local Health District for a ,permit to- construct - <br /> and/or aInostallrthe- work- herein described. This application is made in compliance with San <br /> ,'oanain County erdinance No. 1!862 and. -the Rules and• Regulat ions of the San Joaquin Local Health <br /> Sistr'Ct. / { <br /> 4 EXACT' STREET ADDRESS ✓ CITY/TOWN" •Lc�2�T` <br /> Owner' s Name Phone <br /> Address. City.. Lvt79 <br /> .. .: :.� ,6 �. 12"t . ... <br /> Contractor's Name ,� y` �J� 1 License Z, JV Phone -� T <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOt1 INSURANCE ON FILE WITH SJLHD? YES � NO <br /> TYpE-OFd•WORK (Check :' NW'WEAL L;-� DEEPEN ❑- PRECONDITION QDESTRUCTION d --�` <br /> WELL CHLORINATION Q WELL ABANDONMENT O OTHER O <br /> PUMP INSTALLATION O PUMP REPAIR O, PUMP REPLACEMENT q q� <br /> F <br />' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL ---- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIE ATKNS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> i­— Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven .. Gauge .of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> f Cathodic Protection Rotary Type of Grout''. :° <br /> Disposal { Other Other Information <br /> Geophysical t . Surface Seal Installed by: <br />, PUMP INSTALLATION: Contractor. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: O'State Work Don <br />:PUMP REPAIR: OState Work Done <br /> DESTRUCTION .OF-WELL: WeI°lgDiameterx - """ ""� µ "� -Y ARproxirria`te- Depth— <br /> Describe Material an2 Procedure - <br /> fI 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 A GROUT=-INSPECTION ,PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED � TITLE: DATE: <br /> G--' <br /> � W iI DR WjPLOT PLN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> . . . �� �� <br />:APPLICATION ACCEPTED BY r �,., DATE /! % '7d- <br />(ADDITIONAL COMMENTS : <br /> R PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE /,/ - I INSPECTION BY DATE 3 -z-7- /7 <br /> EH 1426 Rev. 12-77 <br />