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�7q/oY <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 EDate <br /> No. k <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT sued - -7 <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 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 /> k EXACT .STREET ADDRESS ® C � �� CITY/TOWN Z-0-01 " <br /> Owner's Name J..";,, 1 Phone.767 -/Ls'0/ <br /> Address '70P S7 YL VIA <br /> Dr City <br /> Contractor's Name C�27 , C_4 . License# A j Phone 7,ys - 1 , ��- <br /> I5 CERTIFICATE OF WORKMAN'S C0"9PENSATION INSURANCE ON FILE WITH-SJLHD? YES O' <br /> TYPE OF WORK (Check) : NEW_WELL�Z DEEPEN ❑ RECONDITION DESTRUCTION <br /> DESTRUCTION <br /> . WELL CH[OR`�INATION p WELL ABANDONMENT p OTHER <br /> PUMP INSTALLATION Q PUMP REPAIR CI'- - PUMP REPLACEMENT-❑ <br /> t DISTANCE TO NEAREST: SEPTIC TANK1 j,o SEWER•LINES PIT PRIVY 0 <br /> r ' SEWAGE DISPOSAL FIELD I CESS P-FOL/SEEPAGE P�_ OTHER ~ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL— PUBLYTTMESTIC WE=- <br /> I-NUNDED USE' TYPE OF.WELL... ' CONSTRUCTION SPECIFICATIONS <br /> Indos'tr)'al �� Cable—Tool _r. Dia. of Wel Excavation <br /> X Domestic%private, t,N - Dr�;i1ted Dia. of Well Casing <br /> Domestic/public , Dra-en-,,# Gauge of Casing �o <br />' Irri gatj,onGravel--Pack, ,, .Depth of Grout Seal� <br /> Cathodic Protection; , Rotary Type of Grout <br /> t Disposal Other Other Information <br /> x Geophysical Surface Seal Installed : <br /> PUMP INSTALLATION: Contractor x <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done 4 , <br /> PUMP REPAIR: ' <br /> * L7State Work Done <br /> DESTRUCTION OF WELL: We1.lDi?ameter =ApproximateDepth — <br /> DescribeLlMaterial and Procedure. <br /> 6e <br /> I hereby certify that I have prepared this`;applicat tbn and that the work will be done in accordant+ <br /> with San Joaquin County Ordinances , Ttaf6 haws, and Rules and Regulations of the San Joaquin Local <br /> Health District. dome owner 'or l i tensed. agpe,ht''s s gh iture certifies the following: <br /> "I certify that in the performance=df`��he '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 ° c -r .-TITLE: DATE: Z <br /> sD T TLTN_ ON REVERSE SIDE)- <br /> FOR*DEPARTMT USE ONLY <br /> PHASE I <br /> PPLI ATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIUNI PHASE III FINAL INSPECTIO <br /> ,INSPECTION BY DATE INSPECTION BY DATE 3 /�� <br /> EH 14 26 Rev. 9/78 9/78 M <br />