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SAN JOAQUIN LOCAL `HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, ICA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR-WELL CONSTRUCTION OR PUMP .PERMIT <br /> Date Issued <br /> _ This Perm it. Ex ices T 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 /> Joanuin County Ordinance No.- 1862 and the Rules and Regulations ''of the San Joaquin Local Health � <br /> C'i str�ct. <br /> EXACT STREET ADDRESS C�. .. <br /> CITY/TOWiV <br /> Owner' s Name Phone' <br /> - - City <br /> Address � , T ll 4,, <br /> Contractor' s Name �' Licens SV4 ,3 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YE 'JO <br /> STYPE OF WORK (Check) : NEW WELL DEEPEN [] RECONDITION Q DESTRUCTION C1 <br /> E WELL CHLORINATION p WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION D PUMP REPAIR p PUMP REPLACEMENT [ <br /> DISTANCE TO NEAREST: SEPTIC TANK/yQ�ASEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER or <br /> PROPERTY LINE & PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL i CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool I Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> r �.+ <br /> Domestic/public Driven' Gauge of Casing rt. <br /> ' Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �(Rotary Type of Grout „� <br /> Disposal Other Other Information <br /> Geophysical ., Surface Seal Installed b : <br /> V <br /> PUMP INSTALLATION: Contractor ! , <br /> r: Type of Pump H.P. <br /> y <br /> r <br /> f PUMP REPLACEMENT: 7]State Work Done'eX'`,. <br /> PUMP` k A,IR: .p State Work Done V4 lj r <br /> DESTRUCTION OF WELL': Well-�Di.ameter� + Approximate Depth <br /> Describe Materi a and Pr oced ure <br /> tI hereby certify that I have prepared this app,]canon and that the work will be done in accordant <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 /> 3 "I°: certify that in the performance oftbe 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 <br /> TITLE: DATE: <br /> lLTKAW_ PLOT,- N ON `REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE. I <br /> APPLICATION 4ACCEP7ED �BY- y _ DATE y` /97 <br /> ADDITIONAL COMMENTS : w ;• <br /> PHASE II GROUT INSPECTI:ON:t-- �� - �� ' `.PHASE III FINAL INSPECTIO <br /> $,INSPECTION BY DATE INSPECTION BY �. � .• DATE ' <br /> f .� 1/78 2M <br /> cu tinnc .• o.,.. 11377 - � -- <br />