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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FFICE USE: _ 1501 E. Hazelton Ave.-, ,Stockton, CA 95205 Permit No. L� 3 <br /> Telephone: (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> This Permit Ex ires 1 Year From Date Issued <br /> Complete In Triplicate " <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 /> Joaquin County Ordinance No.- 18£2 and the .Rules and 'Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN OG-` rt <br /> Owner's Name—,/—?,9 /111 Phone <br /> Address City <br /> t <br /> Contractor' s Name � License# D 4 Phone � � 1 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOiN I'NSURAtdCE ON FILE WITH SJLHD? YES NO �" 3 <br /> d <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN O RECONDITION DESTRUCTION[] <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 ` OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR El PUMP REPLACEMENT EJ <br /> DISTANCE- TO NEAREST: SEPTIC TANK d-V SEWER LINES PIT PRIVY° <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER n k <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial —x:- Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. -of Well Casing <br /> Domestic/public- ` Driven Gauge of Casing. <br /> Irrigation Gravel Pack Depth of Grout Seal , a <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal " "" Other Other I formati <br /> GeophysicalSurfa eal I to by: <br /> PUMP INSTALLATIO Co `tract rAKT ` <br /> H.P. ; <br /> PUMP REPLACEME T: State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinance's , 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 as to become subject to Workman's Compensation <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLEDATE: ��� 7 <br /> DRAW PL T PL N ON REVERS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY ,,,�� DATE / <br /> ADDITIONAL COMMENTS: = i <br /> PHASE .I I GROUT INSPECTION. .� —, PHASE I I I. FINAL . INSPECTION { <br /> INSPECTION BY DATEINSPECTION BY DATE <br /> Fla 1 d7F, [?nu 1 9_77 1 1-7R ')M <br />