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A <br /> SAN JOAQU1 N LUCAL. HLAL.I H UIS 1 R [;I <br /> FFICE USE: 1601 E. Hazelton Ave. ,Stockton, CA 95205 Permit No.+ � <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires I Year From Date Issued <br /> Complete In Triplicate) —C '2 <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 /> Joaquin County Cr�inance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. r3S - rT !/�� <br /> EXACT STREET ADDRESS rfL� S�ll� �� ' C TY/TOWN <br /> Owner' s Name ,s Phone <br /> Address City <br /> Contractor' s NamE License G Phone —7 /Q <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"1 INSURANCE ON FILE WITH SJLHD? YES NO � <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION ❑ DESTRUCTION[2 � ! <br /> WELL CHLORINATION ❑ WELL ABANDONMENT O OTHER 0 <br /> PUMP INSTALLATION 93/ PUMP REPAIR ❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES��PIT PRIVY • '�" � <br /> SEWAGE DISP SALFIELD -- CESSPOOL/SEEPAGE PIT �'� THER <br /> PROPERTY LINE Z. PRIVATE DOMESTIC WELL ""� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 9.7,,G1< m <br /> Domestic/private —Z---Drilled Dia. of Well Casing <br /> omestic/public Driven Gauge of Casing_ <br /> %epl.� •i <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection rotary Type of Grout_' 2� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor 1 �/4y �J <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done j <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this appl'-ication 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-CAU—FOR A GROOZ, INSPECTION PRIOR TO GROUTING AND A FIN INSPECTION. <br /> SIGNET DATE: <br /> A�A <br /> DRAW PLOT PL REVERSE IDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION aPHASE III FINAL INSPECTION <br /> INSPECTION BY DATE_°-1+71 T INSPECTION BY DATE <br /> EH 1426 Rev. 12-77 1/78 2M <br />