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rM FFiCE USE: 1601 `N JOAQUIN LOCAL HEALTH DISTRIC <br /> �. Hazelton Avg. , Stockton, CA 95205 Permit No. <br /> ` - Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued t � <br /> � (tomplete In Triplicate) <br /> tFplication 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 /> J,Qaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br />�► strict. <br /> EXACT STREET ADDRESS t L_}t. ) �r , CITY/'SOWN <br /> C7 ner's Name Phone ' <br /> Andress City <br /> •'' <br /> C tractor' s Name Li tens=#Ls' "f7 Phone <br /> ' CERTIFICATE OF WORK"iAN'S C0�9PENSATIO'N INSURA"!C- ON FILE WITH SJLHD? YES NO <br /> f .. OF WORK (Check) : NEW WELLA' DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> j � WELL CHLORINATION ❑ WELL ABANDONMENT C1 OTHER 0 � c <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ -� <br />)¢ ;TANCE TO NEAREST: SEPTIC TANK U i SEWER LINES — PIT PRIVY ----- <br /> SEWAGE DISPOS L FIELDCESSPOOL/SEERAGE PIT 1 OTHER <br /> PROPERTY LINE�Q• PRIVA E—DOO S DESTIC WELLS- a2z _ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL OONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> -- Domestic/private Drilled Dia. of Well Casiny _ <br /> Domestic/public Driven Gauge of � asi��u <br /> Irri <br />_`7—Irrigation g Grave] Pack Depth of GroutSea <br /> �,.. Cathodic Protection _Rotary Type of Grout <br /> Disposal Other Other Information -, , � <br /> Geophysical Surface Seal Installed by: <br /> P INSTALLATION: Contractor <br /> z <br /> Type of Pump H.P. <br /> 111P REPLACEMENT: ❑State Work Done <br /> 1( '' REPAIR: ❑State Work Done <br /> SI' RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordant <br /> t San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local. <br /> a th District. Home owner or licensed agent's signature certifies the following: <br /> I certify that in the <br /> not rt to Performance of the work for which this permit is issued, I shall <br /> employ any Person in such manner as to become subject to Workman's Compensation <br /> Flaws of California. " <br /> W_'L CALL FOR, A G UT I SPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> tA <br /> GAZED TITLE: �i� DATE: <br /> DR W PLOT <br /> PLTN ON REVERgSEfSSIDE <br /> A I FO DE ARTMENT SE ONLY <br /> CATION ACCEPTED BY J DATE � �� � <br />] �'IONAL COMMENTS: _�& <br /> PHASE II GROUT INSPECTION PHASE III 'FINAL INSPECTION <br /> �I4_CTION BY DATE I ) NSPECTION BY <br /> s,cn DATE �' <br /> 26 Rev. 9/78 "S"A & sZ-C" _ `s"�o\cg/7R 2M J <br />