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SAN JOAQUIN LOCAL HEALTii DISTRICT <br /> e- <br />-FOR-OFFICE USE: 1601 E. Hazelton Ave. Stockton, CA 95205 Permit No.7 �Q�D <br /> Telephone: 209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued_ -- <br /> APPLICATION <br /> This Permit. Ex ires I 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 />,;oanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Distr!ct. <br /> EXACT STREET ADDRESS / f' CITY/TOWN ' a <br /> Owner' s Name 4 . 1 Phone� a _ <br /> Address City <br /> Contractor's Name r „ License# Phone ri li <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO11,1 INSURAINCE T6a FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLO DEEPEN 0 RECONDITION ❑ DESTRUCTIONED <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER ❑ . <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TAMC/,2e-/ SEWER LINES PIT PRIVY <br /> SEWAGE DISP05AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _Domestic/private Drilled Dia. of Well Casing y <br /> Domestic/public Driven Gauge of Casing oLee <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout a)eeft-e6c _ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor A ,- <br /> Type of Pump �� H.P. i <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 644 J& 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 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 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 TITLE: DATE: <br /> (DKAW PLOT PLTN ON REVERSE SIDE <br /> . FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ///-7 t� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYs,�n DATE <br /> 1/78 _ 2M <br /> ia�� Pau 1�_�� /� _ <br />