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I'U. SAN JOAQUIN LOCAL HEALI'H UlS l k1C I <br /> FQRf FFICE USE: 1601 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. i <br /> F Telephone. (209) 466-6781 <br /> Date Issue <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires 1 Year From Date Issued r <br /> Complete In Triplicate <br /> i Application is hereby made to the San Joaquin Local Health District for a pe <br /> I and/or install the work herein described. This application is made in p ''ia ith San <br />; L'oaq.in County Ordinance No. 1862 and the Rules and Regulations. of the S oa a Health <br /> District. <br /> EXACT STREET ADDRESS C7 C' U CITY/TOWN <br /> Owner' s Name ` Phone <br /> Address v1 Q ` City <br /> Contractor' s Name Licenss06� Phone <br /> IS CERTIFICATE OF WORKMAN'S CORRPENSATION INS URAIN;CE ON FILEATH SJLHD? YES NO <br /> TY,P,E-OF"WORK-(-C-hieck-)-:--NEW-WELL DEEPEN ❑Y '�RE•COND ION- �DES�RIJ�TION <br /> WELL CHLORINATION Q WELL AU DONMENT Q ;OTHER 0 <br /> r PUMP INSTALLATION 0 PUMP AIR O PUMP� REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANKW4/ SEWER LI S PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE OMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDEp USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> r Industrial _Cable T 1 Dia. of Well Excavation - <br /> Domestic/private Drille Dia. of Well Casing <br /> Domestic/public Drive, - Gauge of Casing <br /> Irrigation Gra 1 Pack Depth of Grout Seal <br /> - Cathodic Protection Ro ary Type of Grout <br /> Disposal 0 er Other Information <br /> " Geophysical Surface Seal Installed b ' <br /> 0. <br /> PUMP.-INSTALLATION: .. Contractor <br /> Type of P mp H 1�p — <br /> P RStat Work Done <br /> . POM REPLACEMENT: ❑C <br /> PUMP..REPAIR: ❑St a Work Done <br /> �=DESTRUCi-I-ON--OF--WELL-:— Well -D+ameter—i-- '--,�; % Approx•i-mate�Depth -~- <br /> De ribe Materia and Procedure ' <br /> 4I hereby certify that I have prepared this application and that the work will be done in accordar <br /> , with- San Joaquin Count Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loc2 <br /> Health District. Ho owner or licensed agent' s signature certifies the following: <br /> .'Y certify that ' 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 Cali rn i a. " <br /> I WILL CALL OR GROUT INSPECTION PRIQk TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE.: c <br /> �nowLOT rL N ON REVSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - ~ DATE _L37`y <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> y _ PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> fru I Af)r n. .. `"'1 13 77 <br />