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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 22– (, F � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issuedf�-.^ =� <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. la?360. <br /> EXACT STREET ADDRESS_-- A eAvr� 1 <-- r CITY/TOWN i <br /> Owner's Name �� Phone , _ <br /> Address City L_ car � _.... <br /> Contractor's Name "` �'. s �, r- License ;�; ,W hone 7 3 `7_ <br /> IS CERTIFICATE OF WORK"iAN'S CO"iPENSATION INSURANCE ON FILE WITH SJLHD? YES 0 <br /> TYPE OF WORK (Check) : NEW WELL W-' DEEPEN ❑ RECONDITION [2 DESTRUCTION E2 <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION �'` PUMP REPAIR❑ PUMP REPLACEMENT Q `~° <br /> DISTANCE TO NEAREST: SEPTIC TANK/--,`;6'1Z, <br /> ANK/-;i6> SEWER LINES/Z, — PIT PRIVY <br /> SEWAGE DISPOSAL AL FIELD CESSPOOL;SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE D MESTIC WELL PUBLIC D MESTIC 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 1(-J& _ <br /> Irrigation Gravel Pack Depth of Grout Sea r °r <br /> Cathodic Protection Rotary Type of Grout �`� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor �; 6 - _- � S <br /> Type of Pump r H.P. <br /> PUMP REPLACEMENT: 0 State Work Done <br /> PUMP REPAIR: O State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordanei <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." -A <br /> I WILL CALL FOR A GRO T INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED' TITLE DATE: Y ;;�, ` <br /> MPAQ PL L N ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE �-.- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO / PHASE III FINAL INSPECTION <br /> INSPECTION BY ' . DATE C- -,t 1-1 INSPECTION BY DATE <br /> Ek 74 26 Rev. 9178 9/78 2P4 <br />