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SAN JOAQUIN LOCAL KiEALTH DISTRICT -� <br /> FFICE USE: 1601 E. Hazelton Ave.:; Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466,-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date IssueV, <br /> . <br /> '(Complete In Triplicate) <br /> Application is hereby made to 'the San Joaquin Local Health District for a permit to construct <br /> .and/orinstall 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/TOWN. <br /> ' Owner's Name .g� .Phone <br /> n2- mslk <br /> Address , :City . <br /> Contractor's Name 4License# -Phone <br /> I IS CERTIFICATE OF WORKMAN'S' CO""PENSATIQN INS A"ICE ON FILE WITH SJLHD? " YES NO <br /> TYPE OF WORK (Check) :' NEW WELL PQ DEEPEN Q RECONDITION ® DESTRUCTION[j <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 ,OTHER( w� <br /> : PUMP INSTALLATION M . PUMP REPAIR 0 PUMP" REPLACEMENT ❑ \ <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER L NES PIT PRIVY --- <br /> SEWAGE DISPOSAL FIELDSv 4 CESSP L/SEEP E PIT OTHER <br /> PROPERTY LINP'-(PRIVATE D MESTIC WELL.: -PUBLIC DOMESTIC WELL NQ <br /> j INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia.. af Well Excavation •• <br /> Domes-tic/private - Drilled. a D-4a. -of_ We11-.-Casin <br /> Domestic/public g ` - <br /> � ----=- /p Driven , • ,.. Gauge of Casing—/10 <br /> Jj <br /> -__AIrrigation Gravel Pack Depth of Grout Seal UV <br /> ___L,�._C athodic ProtectionRotar <br /> _• <br /> Disposal -� y :� Type of Grout <br /> Other { � Other Information <br /> Geophysical Surface Seal Installed— b <br /> 001A AJ"011y" PUMP INSTALLATION: Contractor <br /> Type of Pump H. <br /> P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP ,REPAIR: <br /> Q State,Work Done <br /> DESTRUCTION OF WELL: WeI'l`Diameter Approximate Depth <br /> j Describe Material and Proce ure <br /> I hereby certify that l have prepared this application and that the work will be de <br /> in accordanc <br /> i with San Joaquin County Ordinances ,`'-State Laws, and Rules and Regulations of the SanJoaquin .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 /> Taws of California. <br /> I WILL CALL FOR A 0 I P CTION PRIOR T6.79'011T'ING AND A-FINAL INSPECTION. <br /> ,SIGNED - -TITLE: <br /> jrWA, , 1 <br /> PL L N ON REV SI E <br /> EPHASE -I R DEPARTMENT USE ONLY <br />! APPLICATION ACCEPTED BY <br /> ADDITIDNAL COMMENTS: ""' DATE__/,,z A P_—be <br /> PHASE .II GROUT INSPECTION PHASEIII FINAL INSPECTION <br /> INSPECTION BY <br /> - <br /> DATE INSPECTION BYE DATE <br /> 6EH 14 26 Rev. 9/78 A,.-zr%• ,,.. . <br /> - - <br />