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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFIC�E USE: 1601 E. Hazelton Ave. , Stockton,, CA: 95205 Permit No. <br /> Telephone: (209) 466-6781. <br /> r ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> I (i:omplete In Tri'pl i cate) <br /> Application is herebym }i ' . <br /> 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 Nod' 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS �a <br /> CITY/TOWN' <br /> Owner's NameaA)M._ ' Phone <br /> 76 <br /> Address b _ City T' <br /> Contractor's Mame License# ?,3 7� Phone 3 <br /> IS CERTIFICATE OF WORKMAN'S C0111PENSATION- INSURANCE ON FILE WITH SJLHD? _ ' - YES NO i <br /> TYPE OF WORK (Check) : _9 E_W'WELL&f_-DEEPEN Q RECONDITION DESTRUCTION[� <br /> WELL. CHLORINATION Q WELL ABANDONMENT 0 OTHER rJ, � <br /> PUMP INSTALLATION 94 PUMP REPAIR O PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK-7.;" SEWER LI ES..?.,5' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /Do CESSP OL./SEEPAGE PIT i OTHER (' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Wel Excavation. / 4 77 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _ Irri ation <br /> 9 { --.e Gravel Pack Depth of Grout Sea <br /> Cathodic Protection �-Rotary Type of Grout <br /> Disposal Other Other Information <br /> T . Geophysical W <br /> Surface Seal InSta ed : <br /> PUMP INSTALLATION: . . Contractor 1J <br /> Type of Pump TP. 7. <br /> PUMP REPLACEMENT: Q State Work done_ Y" <br /> RUMP REPAIR: <br /> �_ <br /> -� . ❑State Work Done .._. �."'�--�,,.'�-,�{._ '. � ', t <br /> I DESTRUCTION OF WELL: Well. Diameter s �' � <br /> _ .Appraxi.mate_Dep.th- <br /> - Des cri•be---Mate`rla an -P roced u re <br /> } <br /> I hereby certify that I have prepared this applicatton;­and=thatf the work <br /> will be done in accordance <br /> ' w'ith San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin' Local - <br /> H: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, T <br /> 1I. WILL CAL FO A GROUT SPECTION PRIOR TO GROUTING AND A FINAL' INSPECTION. " <br /> SIGNED ' <br /> TITLE: <br /> � DATE: ��' a 7 <br /> .P ON REVERS ADE). <br /> r FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> l'PLI ATI0N ACCEPTED BYi.E <br /> ADDITIONAL COMMENTS: , DATE .� <br /> PHASE It GROUT INSPECTION <br />'INSPECTION BY PHASE III FINAL INSPECTION <br /> DATE `' <br /> INSPECTION BY C . DATE GO z 7 <br /> SEH 14 26 Rev. 9/78 r"ol�q-l�q f o c�49: ... (.-� �.�„�.,1-- ..,. <br />