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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. W;//3T] <br /> Telephone: (209) 466-6781 3-3b-7Y <br /> APPLICATION FOR WELL CONSTRUCTION OR PU�1P PERMIT Date Issued <br /> This Permit Ex ires 1 Year From Date Issued <br /> Comp ete In Trip icate <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> od/or install the work herein described. This application is made in compliance with San <br /> oaouin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> istr•ct. <br /> KACT STREET ADDRESS D j a CITY/TOWN J6('d&" <br /> Nner's Name , / / o K Phone <br /> Jdress a w r City <br /> ontractor's Name Sa a =se( F License# Phone <br /> S CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHO? YES NO k <br /> YPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 _ <br /> PUMP INSTALLATION 11 PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY O <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE -P-f — OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS J <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 Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installe by: �s <br /> JMP INSTALLATION: Contractor h�i urr.e + <br /> Type of Pump —H.P. ;71 <br /> JMP REPLACEMENT: C] State Work Done <br /> JMP REPAIR: ❑State Work Done <br /> STRUCTION 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 accordance <br /> ith San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local <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 Ca if " <br /> WILL CA ROUT INSP IO PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED TITLE: DATE: 3 78 <br /> DR PLOT L ON REVERSE SIDE <br /> FOR D PARTMENT USE ONLY �Ai <br /> 1ASE I / *1 <br /> TP�TION ACCEPTED BY ( M r DATE 3 12,1 79 <br /> )DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I -FI INSPECTION <br /> ISPECTION BY DATE INSPECTION BY — DATE J 78 <br /> I in�a o.... 1 /78 2M <br />