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ri "'Wr N< <br /> S JOAQUIN LOCAL HEALTH DISTRICT <br /> OR FFICE USE: 1601 E: Hazelton Ave. , Stockton, CA 9Sd5 Permit No.,>gg_/5-f2 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> ('Complete In Triplicate) <br /> idlication is herebymade to the San Joaquin Local Health District for a Cgiptorstruct <br /> /or install the work herein described. This application is made in compliance with San <br /> ,aquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> strict. <br /> ;ACT STREET ADDRESS Ati Y_�1 Y/TOW <br /> iner's Name Phone9�,/- 4-1 S� <br /> (dress //0 Lu `Tiu��° CJ�4i� Ci ty S � <br /> )ntractor's Name_ k�) Zet�� Li cense y3 Phone <br /> i CERTIFICATE OF WORKMAN'S COMIPENSATION INSURA°ICE ON FILE WITH SJLHD? YES c - NO <br /> (PE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION Q DESTRUCTION(] <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIRS PUMP REPLACEMENT ❑ <br /> '.STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS�IELD CES�bL/SEEPAGE PIT OTHER t <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4 <br /> Industrial Tool Dia. of We 1 Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout ea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other InformatioT n <br /> Geophysical (� Surface Seal InstaTTed by. <br /> 7MP INSTALLATION: Contractor <br /> Type of Pump i ' - H.P. <br /> UMP REPLACEMENT: ❑State Work Done <br /> UMP REPAIR: (State Work Done <br /> ESTRUCTION 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 accordanc <br /> ith San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <br /> ealth 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 FA A ROUT INSPECTION P IOR TO GROUTING AND�A FINAL INSPECTION. <br /> IGNED TITLE DATE: ZZ-2 !� <br /> _ JC�LOT-nW ON REVERSE VIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ,HAP—LIUTION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: fl <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY �• /� DATE /i / �� <br /> w 1A gr Rnv Q/7A 9/78 2M <br />