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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .,E USE: v 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.>�_r�z .� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year. From Date Issued <br /> Complete In Triplicate /7-7 - q o-- oP <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 /> 4oaauin County Ordinance No. 1862 and the Rules and Begulations of the San Joaquin Local Health <br /> D,isttr7 �' <br /> �EE4d�- a <br /> EXACT STRESS * 4%4wJOWN <br /> % <br /> • <br /> Owner' s Name Phone <br /> Address / 7 ,ro City <br /> Contractor's Name sqj License# /y-�7r-3-Thone 76 74 <br /> IS CERTIFICATE OF WORKMAN'S COM SAT 0�1 I�dSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION C7 PUMP REPAIRM 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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 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 N <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed byi <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: State Work Done hv td Cr <br /> DESTRUCTION OF WELL: Well Diameter OF Approximate Depth <br /> Describe Material an2 Procedure <br /> I hereby certify that I have prepared this application 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 CALL FOR A GROUT INV_ECT1,0N2&0R TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE0,r4- TYLE: DATE: A, <br /> r JZ L T PL ON REVERS SI <br /> FOR DEPARTMENT U ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I L INSPECTION <br /> INSPECTION 8Y DATE INSPECTION BY ATE T� <br /> EH 1426 Rev. 12-77 1/78- -1 M- <br />