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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> V 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit Na. <br /> FOR QFFIC� USE: ^. <br /> Ll�_q-,r Telephone: (209) 466-6781 pate Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires. I Year From Date Issued <br /> Complete In Triplicate l �-3 -- 0 _ <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 a <br /> Joaquin County Ordinance 1�o. 1862 and the Rules and Regulations of the San Joaquin Local Healtl, <br /> EXACT STREET ADDRESS O'rle a,-IVa � � y gCITY/T41�N <br /> Owner' s Name l A> �T' / Phone <br /> Address 3 � City -� <br /> Contractor' s Name Li7ch e# 2, hone <br /> I5 CERTIFICATE OF WORKMAN'S C P SATIOIN INSURANCE OM FILE WITS! SJLHD? . YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN d RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> Industrial Cable Tool Dia. of Well Excavation <br /> - Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> yIrrigation 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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: [] State Work Done ' y <br /> PUMP �. (RState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ana Procedure <br /> I hereby certify that I have prepared this application 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 /> "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." 1 <br /> I WILL CA L FOR A GROUT 'INSP. 0 PRI' TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ITLE: � DATE: tz- <br /> DRAW PLOT PL ON REVERSE SIDE <br /> FOR DEPART ENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY �^— <br /> ADDITIONAL COMMENTS: <br /> PHASE I1 GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY -_ _ DATE 7 - <br /> EH 14.26 Rev: 12-77 1/78 2M <br />