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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF CE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CUCTION OR PUMP PERMIT Date Issued W1.479 <br /> \p (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 ADDRESS CITY/TOWN6 o <br /> Owner's Phone C/d/ <br /> Address S"�.�-rCity <br /> Contractor's Name4ouddu , Licens Phone <br /> � .- �..� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANC ON FILE WITH SJLHD? YES C NO <br /> TYPE 'OF WORK (Check) : NEW WELL Q0 DEEPEN ❑ RECONDITION Q DESTRUCTION ri +I <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 9' <br /> PUMP INSTALLATION Q PUMP REPAIR 0 PUMP REPLACEMENT Q t <br /> 0 <br /> SEWAGE DISP SAL IEL 4 CESSP/OL/SEEPAGE PfT r--_ <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES U 1 PIT PRIVY ---- <br /> � OTHER <br /> PROPERTY LINfifQ-t PRIVATE D ESTIC WELL,L� PUBLIC D MESTIC WELL <br /> INTENDED USE TYPE OF WELL.. CONSTRUCTION SPECIFICATIONS <br /> Industria— 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 Sea <br /> Cathodic Protection -- Rotary Type of Grout u� <br /> Disposal Other Other Information &, � <br /> Geophysical Surface Seal Instb <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure-- <br /> I <br /> roce ureI hereby certify that I have prepared this application and that the work will be done in accordanc <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 GRO T TAP .CT ON PRIOR TO GROUTING AND FINAL INSPECTION. _ <br /> SIGNED TITLE: DATE <br /> D POT PLAN ON REVE SIDE <br /> PHASE I _FO�JEPARTMENTUSE ONLY <br /> PP�LICATION ACCEPTED BY DATE :`Tvvr 7`I <br /> ADDITIONAL COMMENTS: C-19-191 C dt, <br /> �P� <br /> INSPECTION PHASEIII FINAL INSPECT N <br /> INSPECTION BYDATE INSPECTION INSPECTION BY DATE <br /> EH 14 26 Rev. 55" 9/78 29 <br />