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FFICE USE: 'N JOAQUIN LOCAL HEALTH DISTRICT <br /> --Q---_ 1601 c. Hazelton Avq. , Stockton, CA 96205 Permit <br />--� Telephone: (209) 466-6781 <br /> r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (Complete In Triplicate) <br /> leyplication 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 /> IP strict. <br /> M. . <br /> EXACT STREET ADDRESSt c, �� CITY/TOWN __ <br /> Gner's Name <'lxtv(/�l �r Phone t <br /> Andress ,�, City <br /> Crytractor's Name Licens, <br /> LY a #`Ss�Slry Phone <br /> I ` CERTIFICATE OF unRK IAN'S CO*iPENSATI <br /> 0,! INSURA�I <br /> F• <br /> C OP•� FILi HITT!-! SJLHG? YES NO <br /> fFE OF WORK (Check) : NEW WELL DEEPEN 11 RECONDITION CJ_ DESTRUCTION❑ s <br /> k � WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 _ C <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PLIMP REPLACEMENT p -� <br /> TANCE TO NEAREST: SEPTIC TANK Sc) f_1 SEWER LINES — PIT PRIVY <br /> SEWAGE DISPO Lf IELD i.. CESSPOOL/SEEt?AGE PIT ---_OTHER <br /> PROPERTY LINE/A PRI`dAT OMESTIC WELL15a24__ PUBLIC DOMESTIC WELL <br /> . INTENDED USE TYPE OF WELL . CONSTRUCTION SPECIFICATIONS <br /> r,-Industria] Cable Tool Dia. of We11 Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of F;as-icj - 4 <br /> Irrigation - <br /> aravel Pack Depth of Grout Seal <br />�. Cathodic Protection _Rotary Type of Grout1- 10 <br /> Disposal Other Surface Sealeal """r <br /> Geophysical Other TnSion �, . <br /> - <br /> JPP INSTALLATION: Contractor <br /> 1t Type of Pump H.P. <br /> SMP REPLACEMENT: ❑State Work Done <br /> P k. ' REPAIR: ❑State Work Done <br />" <br />:S UCTION OF WELL: Well Diameter <br /> Describe Materia and Procedure Approximate Depth <br /> F*1 <br /> hereby certify that I have prepared this application and that the work will be done in accordant <br /> t-4 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 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 /> -!L CALL FOR,. A G UT I SPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> Gr-_D <br /> T - TITLE: DATE: • ? <br /> (DRAW PLT L N ON REVERSE SIDE <br /> AW I FO DE ARTMENT SE ONLY <br /> CATION ACCEPTED BY <br /> i�IONAL COMMENTS : DATE �_? <br /> PHASE II GROUT INSPECTION <br /> CTIPHASE III FINAL INSPECTION <br /> ON BYDATE [v <br /> 14 26 Rev. 9/78SPECTION 8Y DATEi, <br />