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Pr <br />--.—'. 4, _.. SAN JOAQUIN LOCAL HEALTH DISTRICT <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 1 Year From Date Issued <br /> Complete In Triplicate) ' <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 madein compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN____,! _ <br /> Owner' s Name c/c T a Phone <br /> Address 1 $4, 3 910'' *41X&4 AVz City <br /> Contractor's. Name - License# /93 7 Phone cA 7-4 <br /> IS CERTIFICATE OF WORKMAN'S rr1QPAATTnt1 INSURANCE ON FILE WITH SJLHD? YES ?C NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ -� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 "C <br /> PUMP INSTALLATION ❑ PUMP REPAIR" PUMP REPLACEMENT[] W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP--G—OL/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 r <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor f� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: $a State Work Done ` ��e m �,/�! Aly' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's. Compensation <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECT ON PR TO GR UTING AND A FINAL INSPECTION. <br /> SIGNED;' ITLE: DATE: Q <br /> DR W PLD—T--PPlW ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE to ?/7 V <br /> ADDITIONAL COMMENTS: -r— <br /> PHASE II GROUT INSPECTION PHA$E III INAL INSPECTION �� <br /> INSPECTION BY DATE INSPECTION BY DATE -X <br />_H 1426 R _ 78 2M <br />