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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.79 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -3-7 <br /> (Complete In Trip 1'icate) <br /> Application is hereby made to the San Joaquin Local Health- District fora permit to construct <br /> and/or ,.install the�work herein described. This application is-made in compliance with San <br /> Joaquin Cunty;Ordinance No.! 18.62 and the Rules and, Regu lations of- the San Joaquin Local Health <br /> ' District. <br /> EXACT STREET ADDRESS re 7cS ,d' CITY/TOWN. <br /> Owner's Name r--°7 i Phone <br /> Address ; Ci-ty <br /> t 'r <br /> Contractor's Nam Li cense# l��.7 kJ'-1Fo_9e_ b �' <br /> IS CERTIFICATE OF WORKMAN'SICO"i SA�ION INSURANCE ON FILE WITH SJLHD? YES D <br /> TYPE OF' WORK (Check) : NEW WELL DEEPEN ❑ RECONDITIONA DESTRUCTION <br /> i y WELLCHLORINATION Q WELL ABANDONMENT OTHER[] .� - -- <br /> r PUMP INSTALLATION ❑ PUMP REPAIR PUMP REPLACEMENT,Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. .. PIT PRIVY <br /> SEWAGE DISPOSAL .FIELD CESSPOOL/SEEPAGE PIT OTHER V <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> " INTENDED USE TYPE OF WELL I CONSTRUCTION SPECIFICATIONS <br /> - Industrial Cable Tool Dia. of Ve—Iff Excavation <br /> ( X Domestic/private Drilled Di-a. of• Well . Casing <br /> Domestic/public Driven ' Gauge of Casing <br /> •.Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type=of GroutW <br /> ` Disposal Other Other Information <br /> Geophysical - f Surface Sea..- Insta ed by: <br /> PUMP INSTALLATION: Contractor <br /> TypelP.Pump H. <br /> PUMP 'REPLACEMENT: ❑State Work Done ' <br /> PUMP REPAIR: (.State Work Done I/' <br /> DESTRUCTION OF WELL: Well' Diameter Approximate Depth w <br /> Describe Material and Procedure <br /> I hereby certify.that I have prepared this application and that the work will be done in accordan <br /> with San Joaquin County Ordinances , State Laws,, and .Rules and Regulations of the San,Joaquin -Luca <br /> Health"District. Home owner or licensed agent's signature certifies the following: <br /> "'I certify that in the p6rformance of the work for which this permit is issued, I shall <br /> not employ any person insuch manner as to become subject to Workman's Compensation <br /> laws of California. " kt F <br /> I WILL .FQR A GROUT INSPECTIO. PRI R T OUT ;NG AND A'FINAL''TI-NSPECTION. <br /> SIGNED Dl! in DATE: <br /> PL T PL N REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY . <br /> PHASE I <br /> .APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: el <br /> PHASE II GROUT-INSPECTION 'PHASE III FINAL INSPECTION <br /> ;INSPECTION BY DATE INSPECTION BY Q --r DATE r <br /> EH 14 26 Rev. 9/78 .. - � . -.'-1 -.. .1 _,9/78.. 2M <br />