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f t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE U�E 1601 E. Hazelton Ave. , CA 95205 Permit No. <br /> Stockton, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued_6-?8 77 <br /> (t;'olnplete In Triplicate <br /> 2`(-f-3 bbO —3� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct_ <br /> rand/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 /> i EXACT STREET ADDRESS � 1 � � ,� ',, _ <br /> ;Owner's Name ' ITY/TOWN <br /> �A <br /> �� <br /> Address Sl 51 Phone <br /> contractor's Name City <br /> .t , r Li cense��" /Phone 14. <br /> IS CERTIFICATE OF WORKMAN'S COtRPEPdSATI0P1 INSURANCE ON FILE WITH SJLHD? - YES N0 <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN ❑ RECONDITION C3 DESTRUCTION d <br /> WELL CHLORINATION 0 WELL ABANDONMENT C1 OTHER 0 . <br /> PUMP INSTALLATION o"01PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST. SEPTIC!TANK/ ( SEWER LINES " PIT PRIVY <br /> SEWAGE DISPOiIELD CESSPOOL/SEEPAGE —P17— OTHER <br /> PROPERLY LINE ATVATE DOMESTIC WELL PUBLIC DOMESTICE1� L� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> In ustr Cable To Dia. of Well Excavation <br />___Domestic/private Drilled Dia. of Well Casing <br /> iDomestic/public Driven <br /> rrigation Gauge of Casing <br /> Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary T <br />,_______Disposal Other tof Grout <br /> Geophysical Othhe er Information <br /> Surface Seal Insta ed b : <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump ar f W. . <br /> PUMP REPLACEMENT: <br /> (State Work Done <br /> RUMP REPAIR: ❑State Work Done <br />)ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Proce ure Approximate Depth <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br /> O th San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Cealth 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 /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A INAL INSPECTION. <br /> IGNED '" <br /> TITLE: '6 Viz ... DATE: <br /> = _ D W P T L ON REVERSE SIDE ` <br /> EASE I EOR DEP RT N USE ONLY <br /> 5PLI ATION ACCEPTED BY <br />)DITIONAL COMMENTS: , DATE -7�. <br /> PHASE II GROUT INSPECTION <br /> SPECTION By DATE PHASE III FINAL INSPECTION <br /> 74 26 Rev. 9/78 INSPECTION 8Y DATE. <br />