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SAN JOAQUIN LOCAL HEALTH UISIKICI <br /> r FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. '7 <br /> Telephone: (209) 466-6781 3 <br /> I— 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 made in 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, %�� �,,�„�► ,00 , Q ,� -.,�4,,L / CITY/TOWN <br /> Owner's Name /3 ;� �„ ,,,,] Phone92 :?9 <br /> Address 22011 S City <br /> Contractor' s NameLicense# 323 Phone 6�-- ��S <br /> ':S CERTIFICATE OF WORKMAN'S C011.1PENSATIO"1 INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION <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 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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <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 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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �,�,�y �x,�� TITLE: �� Q p,,ev DATE: <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED' BY DATE 3-fib'-�� <br /> ADDITIONAL COMMENTS: <br /> PHASE-,II .GROUT INSPECTION PHASE II FIN.AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE —ZZ <br /> EH 1426 Rev. 12-77 1/78 2M <br />