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Ce�� Ptst SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7g_/,��> <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued s�� <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 theworkherein described. This application is made in compliance with San <br /> Doaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. -Pan <br /> EXACT STREET ADDRESS L A- CITY/TOWN <br /> Owner' s Name C 44--X,— Phone <br /> Address City so _ <br /> Contractor' s Name License ,3 �7hone r ,�. -79 �'i�6 <br /> IS CERTIFICATE OF WORKMAN'S MN ATIm INSURANCE ON FILE WITH SJLHD? YES " NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIRCM 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 -J <br /> Type of Pump H. 1 <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: RState Work Donee <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 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." <br /> 1 WILL CALL FOR A GROUT I TI IOR TO GROUTING AND A FINAL INSPECTION. <br /> SIG TITLE: DATE:_ <br /> W PLOT PE N ON REVERSE SIDE { <br /> FOR DEPARTMENT U E ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYA�� ZA" DATE v �� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIJINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 R 1/78 2M <br />