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1 <br /> SAN JOAQUIN LOCAL HEALTH 0151RICI � <br /> FOR FFICE USE: 1601 E izelton Ave. , Stockton, CA 9. 5 Permit No. 79-aL <br /> telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -13-79 <br /> This Permit Ex fres 1 Year From Date Issued <br /> (Complete In Implicate) <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 />.:oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADORES$ #3i icy P � CITY/TOWN �C <br /> Owner's Name j�, ,z C',,.L.rtE�6 Phonep3-Z <br /> Address eo /j*y- City (. ,• <br /> Contractor' s Name j Licensees+tpoy- Phonef3�= •%.zi <br /> ': S CERTIFICATE 0 IJORKIIAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br />.TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ ; DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT O OTHER 0 fi <br /> PUMP INSTALLATION S PUMP REPAIR 0. PUMP REPLACEMENT ❑ W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP S1�AL—FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELLZn <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of WeF1 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 InstaTTed by: <br /> PUMP INSTALLATION:• Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work. one <br />'PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mate;ial and Procedure <br /> I hereby certify that I have prepared thjs application and that the work will be done in accordanc <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <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 ds to become subject to Workman's Compensation <br /> laws of California." • <br /> I WILL C -A ROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEp TITLE: DATE:_ -/�7 `1 <br /> D W L N ON REVERSE SIDE <br /> R R DEP RTMENT USE ONLY <br /> 3HASE I <br /> 4PPLICATION ACCEPTED BY�f =6�2�au� �Y� ^ DATZO ..�rr <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E III--FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION B 6rrt/ DATE6( <br />