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(b SAN JORQUIN LOCAL .HEALT.H DISTRICT 5bFFICE USE: 1601 E. -Hazelton Ave. , Stockton, CA 95205 Permit No. �6 Telephone: -(209) 466-6781 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /-�- 7 y (Complete . In Triplicate), Application is hereby made to the San Joaquin Local Health, District- for 'a- permi�tito construct and/or install the work herein described. This application is made -An compliance'-with-_ San Joaquin County Ordinance No. 1862 and the Rules and Regulati-ons of the San Joaquin Local Health District. EXACT STREET ADDRESS '. y`"� + $' CITY/TOWN ' Owner's Name Phone Address _.. Y - L Ci ty ,. , Contractor's Name �- Licensee Phone �t6 --Z-74 IS CERTIFICATE -'OF WORKMAN'S Cok EN ATION INSURANCE ON FILE-WITH SjLHD? YES NO TYPE OF WORK (Check) : NEW WELL Ci DEEPEN CI RECONDITION DESTRUCTIONS, .. .. - - WELL 'CHLORINATION C1 WELL ABANDONMENT 0 OTHER 6-1 PUMP INSTALLATION PUMP REPAIR L1 = PUMP REPLACEMENT DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. ._ PIT PRIVY Gam' SEWAGE .DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER PROPERTY LINE - PRIVATE DOMESTIC WELL-- - PUBLIC DOMESTIC WELL INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS.- Industrial Cable Tool Dia. of Well Excavation Domestic/private Drilled Dia. of Well Casing g Domestic/public Driven Gauge of Casing �yIrrigation Gravel Pack Depth of Grout Sea Cathodic ProtectionRotary Type of Grout . - Disposal Other Other Information Geophysical - Surface Seal ' Insta a 'b : PUMP INSTALLATION: Contractor Type of Pump H. T. ._ PUMP REPLACEMENT! [❑State Work Done �- PUMP ;&;Zpw.. ['State Work Done - ��,,,,�� DESTRUCTION OF WELL: Well Diameter _ - Approximate,Depth Describe MateF151 and Proce ure I hereby ,certify .that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances , State Laws, and. Rules and Regulations of the Sara°Joaquin Local ' Health District. ' Home owner, or Ticensed agent' s signature certifies the following: ' "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in' such manner as to become subject to Workman's Compensation laws of California. I WILL CAS FOR A GROUT INSPECT PRIQ, -;4 GROU ING- AND A :FINAL INSPECTION. S.IGNE -E: r DATE: $� N REVERSE SI. R DEPARTMENT USE ONLY PHASE I APPLICATION ACCEPTED BY /Z,, DATE ?� ADDITIONAL COMMENTS: PHASE II GROUT INSPECTION I PHASE III FINAL INSF CTION INSPECTION BY DATEr INSPECTION BY DATE� -� EH 14 26 Rev. 9/78 .. ..w . =9/78 2M, .,;