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SAN JOA QUIN -LOCAL HEALTH DISTRICT <br /> 5E. -OFFICE USE: 1601 E. Haze'lton..Ave. , Stockton, CA 95205 Permit No. , ` <br /> Telephone: (209) 466-6781 _ <br /> W APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued S "7S"' <br /> This Permit Expires I Year From Date Issued { <br /> Complete In Trip icate <br /> Application is hereby made to the San Joaquin Local .Health District fora permit to construct <br /> and/or install the work herein described, This .ap'plication is made' in compliance with S.an <br /> ,'oaouin County Ordinance No.. 1862 and the Rules and Regulations of the SaLoc <br /> n Joaquin al Health <br /> District. ; <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name P h on' e_a 6f" r{,{9 t <br /> Address " ofI AJ C City <br /> Contractor's Nameezo <br /> License# d `, Phone S'�3 ��� k F <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA*1 Ord FILE WITH SJLHD? YES c— NO „ f <br /> TYPE OF WORK (Check) : NEW WELL P-1 DEEPEN ❑ RECONDITION DESTRUCTION M <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC-TANK ��. SEWER= LINES— ­-PIT-PRIVY-- <br /> SEWAGE <br /> -PIT-PRIVY----SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q <br /> PROPERTY LIN O.'PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> l.\ a. r t ,r <br /> INTENDED?J TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia. of Well Excavation zz. <br /> e.�-Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing .� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection &.—Rotary Type of Grout bl <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump H; <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter APProximate,Depth" <br /> Describe Mate-Fial and Procedure A <br /> y certify that I have repa this_ a 1..i cati on-an.d-that-the.-work-fwa 7:1-be-done-i n_a-ccordance. <br /> I hereby _ F <br /> writF-8ari Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Local ' <br /> lealth 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. " t£ . <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> SIGNED TITLE: DATE: ' <br /> DR W PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />)HASE I <br /> PPS LICATION ACCEPTED BY DATE "-] � g` , <br /> kDDITIONAL COMMENTS: - - <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION ' <br /> NSPECTION BY DATE INSPECTION BY DATE i <br />'H 1426 Rev. 12-77 <br />