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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> a OR OFFICE USE: 1601 E. Hazelton. Ave. , Stockton, CA 95205 Permit No.79/,;t <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �7 <br /> This Permit Expires 1 Year From Date Issued <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 /> Di stl'ri ct. <br /> EXACT STREET ADDRESS �.S . c.Y CITY/TOWN <br /> Owner's ,Name Phone <br /> Address QAZ Ci ty 1—f, "Z+_ C _ <br /> Contractor's Name ��� , C.T� Li cense# Q Phone �-� 11 k _ <br /> TS CERTIFICATE OF WORKMAN'S C01,1PENSATIOIN INSURANCE ON FILE WITH SJLHD? YES TNO <br /> TYPE OF WORK (Check) : NEW WELIAM DEEPEN ❑ RECONDITION ❑ DESTRUCTION[] W <br /> WELL CHLORINATIONWELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION I� PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD . CESSPOOL/SEEPAGE PIT OTHER <br /> • PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLTC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 4 Domestic/private _Drilled Dia. of Well Casing r <br /> Domestic/public Driven Gauge of Casing 1 ,� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout T <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 'Sem ��_ H.P. MV f <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 hereby certify that I have prepared this application and that the work will be done in accordance <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, 1 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 E.Q A ROU I SPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DRAW PLOT L N ON REVERSE E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I P -- <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II . GROUT 1-NSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> EH 1426 Rtem__12-77 8�4T 41/78WM <br />