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Co vs, W/*14ZO( SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFI E USE: ' 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 73f--/w16D <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �8 <br /> This Permit Exires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> S %H•/m <br /> EXACT STREET ADDRESS. i',L Gf./ar 2 G9 m krr„s CITY/TOWN <br /> Owner's Name Phone <br /> Address l izGaCity �Q <br /> Contractor's Name�c/' a0' JEM License# hone��y --2&2y- <br /> IS CERTIFICATE OF WORKMIAN'S CO ENSATIO41 INSURANCE ON FILE WITH SJLHD? YES 'C NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT p OTHER a <br /> PUMP INSTALLATION ❑ PUMP REPAIROn PUMP REPLACEMENT ❑ <br /> DISTANCE 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 i4 <br /> _Domestic/private Drilled Dia. of Well Casing f <br /> Domestic/public Driven Gauge of Casing <br /> _Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other InformatT ion <br /> Geophysical Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ®State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> with 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 CALL FOR A GROUT INSPECTPRIO 0 GROUTING AND A FINAL INSPECTION. <br /> SIGNED LE: DATE: T 7Q <br /> D W P T P ANnN REVERSE SIDE <br /> R DE TMENT USE ONLY <br /> MASE I v DATE D �� <br /> 'PLICATION ACCEPTED BY .= <br /> ADDITIONAL COMMENTS: <br /> ECTION <br /> PHASE II GROUT INSPECTI PHA <br /> INSPECTION BY DATE INSPECTION B DATE �Z <br /> _.. 1/78 2M <br /> EH 1426 Ray. 12-77 <br />