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SAN JOAQUIN LOCAL HLALIH U15IkICl <br /> FFICE USE: 1601 E. Flazelton Ave. , Stockton, CA 95205 Permit No. 2f—47 S <br /> Telephone: (209) 466-6781 T <br /> ----- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �-i?� 7� <br /> This Permit Expires I 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 /> acid/or irstall the work herein described. This application is made in compliance with San <br /> �paC71�n County Ordinance 1,o . 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> r_, <br /> v <br /> EXACT STREET ADDRESS 7 CITY/TOWNr <br /> Owner' s Name _ � � Phone <br /> Address Ci ty <br /> Contractor' s Name License#_-33 7! Phone � 1 <br /> IS CERTIFICATE OF WORKMAN'S CO', 1,)ENSATIO"1 I{ISURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ �'� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHERID <br /> PUMP INSTALLATION ' PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITOTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL IC_PUBLDOMESTIC_ 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 ,p4 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: M State Work Done <br /> PUMP REPAIR: Q 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 CAL,6=90 A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DRAW PLOT PL N ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> , <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION - PHASE III FINAL INSPECTION <br /> INSPECTION By DATE INSPECTION BY DATE ,I�-18 <br /> EH 1426 Rev. 12-77 1 /78 2M <br />