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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> JOR OFFICE .USE: 1601 iazelton RVe7r$tockton, CA 05 Permit No. 79- <br /> Telephone: .{209) 466-6781. <br /> APPLICATION FOR WELL• CONSTROCTION OR PUMP PERMIT Date Issued.�_�z-79 <br /> This ,Permit Ex ires '1 Year From Date Issued <br /> (Complete . n Trip icate o <br /> Application is hereby made to, the- San Joaquin Local Health District for a permit to construct 4- <br /> and/or install the work herein described. This application. is made in compliance with San <br /> JoanUin County- Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health `h <br /> District. 1 <br /> EXACT STREET ADDRESS (c ["zi/.r it. -4 CITY/TOWN — <br /> Owner' s Name Phone <br /> Address ZC) :/ City � — <br /> Contractor' s Name L i c e n s e#� 4fZ3- Phone <br /> IS CERTIFICATE OF WORKMAN'S MPENSATInm INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0� OEEPEN ❑ - 'RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 A <br /> PUMP INSTALLATION .❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> 31STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSALELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF W4LL CONSTRUCTION SPECIFICATIONS <br /> Industrial . Cable- ool pia. of Well Excavation <br /> T/Domestic/private Drilled Dia. of Well Casing . <br /> Domestic/public Driven.i - Gauge of Casing <br /> Irrigation Gravel ',Pack Depth of Grout Sea 21-dl <br /> Cathodic. Protection vRbtaryType of Grout <br /> Pisposal 7Qt her Other Information4 + <br /> Geophysical - Surface Seal Insta ed b <br />-)UMP INSTALLATION: Contractor <br /> Type of Pumpr' H. <br />''UMP REPLACEMENT: [D State Work Done e <br /> LUMP REPAIR: Q State Work Done <br />)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> DescribefMateridl and Procedure , <br /> d hereby certify that I"have prepared this application and that the work will be done in accordant <br /> lith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br />•lealth 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 employWOUj:��PE <br /> erson in such manner as to become subject to Workman's Compensation <br /> lad oaf Caliia <br /> WI CALL FORTION RI-GR- TO GROUTING AND A FINAL INSPECTION. <br />.IG 1. <br /> TITLE: DATE: <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />'RASE I <br /> APPLICATION AECEPTED BY i✓ DATE,7-4f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE :�,--,-7 - 'i <br />