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SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> FOR.OFFTrE USE: . 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. /
<br /> Telephone: "(209) 466=6781
<br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued
<br /> (Eomplete In Triplicate} n �,
<br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct
<br /> k and/or install the work herein described. This application is made yin compliance with San
<br /> Joaquin County Ordinance No:' 1862 and the Rules and- Regulations of the San Joaquin. Local,.Health `
<br /> District. S�y2 /
<br /> EXACT STREET`ADDRESS -2o A/ ,,,,,,,v 4"e CITY/TOWN
<br /> Owner's Name f ,gyp, -Phoned '-,
<br /> i
<br /> Address . City z��i,. -
<br /> Co.ntractor'_S.Name .vt - ,` Via. Licensef 1-6 Phone 1�1.7;?X
<br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES
<br /> � 1'YPE,Q_F, WORK (Check) : �1VEW WELL 0 DEEPEN O RECONDITION ❑ DESTRUCTION❑ - F.
<br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑
<br /> RUMP,INSTALLATION ❑ PUMP REPAIR[J-- PUMP REPLACEMENT Q o
<br /> DISTANCE TO'NEAREST_ SEPTIC 4ANK��p��__� SEWER LINES_jj�����A PIT PRIVY-c
<br /> •.__ S'EWAGE 'DISPOSff IELD >.vo"' CES--SPOOL/SEEPAGE PI��-� OTHER' s ,
<br /> PROPERTY LINE iFRIVATE DOMESTIC WELL_ PUBLIC DOMESTIC ,WELL
<br /> .INTENDED OSt" TYPE OF-WELL.., CONSTRUCTION SPECIFICATIONS
<br /> Industri aZ - - - Cable T661' -- Di-a-.,_af Well Excavation IL 1�u All
<br /> om sticJpriVate'"`"""'- " UH_T Td__""�D a-z, f`Well Casing_
<br /> EDomesti c/public Driven Gauge ofTGas i=ng �f �
<br /> Irrigation Gravel Pack Depth of Grout -Sea
<br /> Cathodic Protection Jt Rotary Type of Grout'p�,,,, ,./ �� r
<br /> Disposal ` Other Other Information, \
<br /> Geophysical w Surface Seal Installed :Vrlw, Al,,. G
<br /> PUMP -INSTALLATION: Contractor T,
<br /> Type .:of Pump
<br /> H.P.
<br /> PUMP REPLACEMENT: []State Work Done ,
<br /> PUMP REPAIR: ❑State Work Done
<br /> DESTRUCTION OF WELL: Well Diameter Approximate -Depth
<br /> Describe Materia an Proce ure
<br /> I hereby certify that I havelprepared 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 followin .
<br /> "I certify that in the performance of the work for which this permit is issued, I�ishall
<br /> not employ any person in such manner as to become subject to Workman's Compensation'
<br /> elaws of California." � .
<br /> kI WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION.
<br /> SIGNED=.f TITLE: DATE: r�=-27-?,9 ,l
<br /> ' ""• (DRAW PL N ON ..REVERSE- SIDE
<br /> ---FOR EP. RTMEN.-.USE_ONLY. ,-,. -- .,...- --,�.�-.=.....-
<br /> 1PHASE I .�""",. - �
<br /> r PP� LIGATION ACCEPTED BY f
<br /> DATE
<br /> ADDITIONAL COMMENTS: ,
<br /> PHASE I GROUT INSPECTION PHASE III FINAL INSPECTION'
<br /> INSPECTION BY DATE INSPECTION BY ,
<br /> DAJT
<br /> EH 14 26 Rev. - 9/78 9/78 2M s
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