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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> =!FQR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. , 33 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /- 7 <br /> (Complete In Triplicate) <br /> -replication 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 /> Daquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> ,istrict. <br /> EXACT STREET ADDRESS // ,3 / CITY/TOWN <br /> ner's Name le �or L . Vee /1; Phone �IK �S - 6sv- 1, <br /> Address -ts—�.�.+�` City 22t� � <br /> _)ntractor's Name l! F License l/I/ Phone 16 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA"dCE N FILE WITH SJLHD? YES .Y No <br /> _(PE OF WORK (Check) : NEW WELL 0 DEEPEN IB( RECONDITION 0 DESTRUCTION[( (� <br /> WELL CHLORINATION 0 WELL ABANDONMENT ® OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR O PUMP REPLACEMENT ❑ <br /> 'M STANCE TO NEAREST: SEPTIC TANKS SEWER LINES,p �t PIT PRIVY <br /> SEWAGE DISPOSAL 1 FIELD/} + CESSSP 0-L/SEEPAGE PIT OTHER <br /> PROPERTY LINV0 4PRIVATE DOMESTIC WELLJ;t> -- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ / Cable Tool Dia. of Well Excavation711 <br /> 'Domestic/private Drilled Dia. of Well Casing ,,,,r// li <br /> Domestic/public Driven Gauge of Casing A-JAL l_ <br /> Irrigation Gravel Pack Depth of Grout Sea] <br /> Cathodic Protection Rotary Type of Grout -- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed y: <br /> JMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> "'JMP REPLACEMENT: 0 State Work Done <br /> JMP REPAIR: ❑State Work Done <br /> nESTRUCTION 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 accordam <br /> ith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <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 /> laws of California." <br /> I WILL CA FOR GRO T I SP TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED TITLE: tk DATE: <br /> (DRAW PLOT PLAN ON REVERS , IDE <br /> 1ASE I FOR DEPARTMENT USE ONLY <br /> 'REPLICATION ACCEPTED BY _ ` DATE L /979 <br /> 4DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> "SPECTION BY nll DATE INSPECTION BY DATE 'S \-) I )? <br /> -11 1 � 11 n_ n .�.. <br />