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JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 16,01i--"'Hazelton Ave. , Stockton, CA 9ae05 Permit No. 79�-0 7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - 3'J <br /> This Permit Ex ires 1 Year From Date Issued <br /> Complete In Triplicate <br /> 3plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein described. This application is made in compliance with San <br /> Danuin County Ordinance ",o. 1862 the Rules and Regulations of the San Joaquin Local Health <br /> XXct. <br /> ACT <br /> ACT STREET ADDRESS an _� O� CITY/TOWN <br /> 44 <br /> aner's Name S � .�'01�` �5 Phone � <br /> ddress City dam. <br /> ontractor' s Name 1-7-fi License#/6- 9 Phon <br /> ;7gZ 16 <br /> S CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES °—� NO <br /> YPE OF WORK (Check) : NEW WELL❑ DEEPEN D RECONDITION ❑ DESTRUCTION D <br /> WELL CHLORINATION D WELL ABANDONMENT O OTHER D C <br /> PUMP INSTALLATION CY PUMP REPAIRC3 PUMP REPLACEMENT D <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation t <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> 'UMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> 'UMP REPLACEMENT: ❑ State Work Done <br /> 'UMP REPAIR: [tate Work Donil <br /> )ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordar <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Locc <br /> iealth 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 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> DATE: ,i'.9 - 79 <br /> SIGNED DRAW PL T PL N ONTREVERSE SIDE FOR DEPARTMENTUS ONLY <br /> DATE <br /> .344�, <br /> PHASE I <br /> APPLICATION ACCEPTED BY Y ti <br /> ADDITIONAL COMMENTS : 1/ 1 <br /> PHASE II GROUT INSPECTION VPHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 /7R 21 <br />