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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.,7e_1_jj-y <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued�_.5-->� <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 withn <br /> ,oanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Loc Health . <br /> District. <br /> EXACT STREET ADDRESS _ �,.�,� �,�rl ,, ,',� �n ,, '-„ ,,,�r, jg CITY/TOWN coo <br /> Owner's Name Phone <br /> Address 7,/2 rn Va-/� O C i ty�- <br /> Contractor's Name License# 1183 7iq�Phone V47 - 74 7 <br /> IS CERTIFICATE OF WORKMAN'S COs NSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION 6a 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 r-” <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP RfrA R: RState 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 accordanc <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 INSPECTI PRIG 0 GROUTING AND A FINAL INSPECTION. <br /> SIGNED ITLE: DATE: 8 <br /> W PLOT PL ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1'�- DATE > 177 _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /O /,Z <br /> EH 1426 Rev. 12-77 1/78 2M <br />