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f !&: <br /> �,�.j�4.:_ SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 'y <br /> f Telephone (209) 466-6781 fo <br /> i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit- Expires 1 Year From Date Issued <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 therwork herein described. ' This application is made in compliance with San <br /> ', ,.'oanuin County Ordinance No. 1862 and the Rules and Regulations. of- the San Joaquin Local Health <br /> iDistrict. <br /> k EXACT STREET` ADDRESS .boa CITY/TOWN <br /> Owner' s Name , Phone <br /> Address Al City <br /> ZGContractor's Name Hp _ <br /> V. <br /> IS CERTIFICATE OF WORKMAN'S' COI ENSATIO 1 INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION[] <br /> WLL1�` CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER,O <br /> PUMP; INSTALLATION C7 PUMP REPAIR❑ PUMP REPLACEMENT ) q p <br /> i' . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ; PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION; SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavatibn C3 <br /> X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/,public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal i _ <br /> Cathodic Protection Rotary Type of Grout <br /> DisposalOther Other Information f <br /> Geophysical r. +. Surface Seal Installed by: <br /> `. PUMP INSTALLATION: Contractor c- <br /> Type .of Pump , A. H.P. " <br /> I PUMP REPLACEMENT: X State Work Done ,�,,,�,� ,�, / m�-- 0- <br /> 16.0 V <br /> ` PUMP REPAIR: ❑State Work Done <br /> .4, A I <br /> ( DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ' r <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 INSP T , N ,,PR R TO GROUTINGj'AND A FINAL INSPECTION. <br /> + SIGNED ,.. ITLE: �.�t DATE: S �� <br /> -(DRAV TT OT PL —nN REVERSE SIDE <br /> FOR DEPARTMENT USE. ONLY <br /> PHASE I k <br /> APPLICATION ACCEPTED BY DATE <br /> `ADDITIONAL COMMENTS: -� <br /> PHASE II GROUT/;A$PE-CT-10 PHASE III FINAL INSPECTION <br /> INSPECTION BY INSPECTION BY ,1° DATE 7� <br /> `Pu 1A99 Do 1 0-'77 w�„ 1 /79 2M <br />