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S, JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E)�rKazelton Ave. , Stockton, CA 95rsi Permit No.7y_�oFr <br /> CC, <br /> - J Telephone: (209) 466-6781 <br /> Date Issued 3- 9- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex fires 1 Year From Date Issued <br /> Complete In Triplicate <br /> ,lication is hereby made to the San .loaquin Local Health District for a permit to construct <br /> :/or install the work herein described. This application is made in compliance with San <br /> ;rijin County Ordinance 1+o . 1862 and the /RRuuulleess,-,and Regulations of the San Joaquin Local Health <br /> trice. d,?"�" J �,�'NR6n <br /> :CT STREET AD SS U� CITY/TOWNSP' <br /> :er's Name d ��— P`'d29rlf- Phone /+► — <br /> '.ress Ci ty <br /> itractor's Name License#/ 'a--73 Phone <br /> CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES <br /> PE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ au �6e- • <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ( <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACE NT <br /> STANCE 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 d� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <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 /> :MP INSTALLATION: Contractor <br /> Type of Pump H.V. <br /> IMP REPLACEMENT: ❑ State Work Done <br /> 1MP REPAIR: C2<tate Work Dol% / <br /> :STRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material ana Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordan <br /> ith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <br /> �alth 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 /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> :GNED TITLE: , . __ DATE: 1.4- 79 <br /> �— DR W PLOT PLAN ON REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> MASE I DATE <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE <br /> L°-. i /7R 2 <br />