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SAN JOAQUIN LOCAL HEALTH DISTRICT ----- <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 4:66-6781 <br /> 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 (j �; �} �.,�'�/? c: CITY/TOWN <br /> Owner's NamePhone <br /> Address 4 . a022 City <br /> Contractor's Name ��•cr. Li cense# 4/WA Phone jt.? --66 <br /> 7 <br /> IS CERTIFICATE OF WORKMAN'S COMPEN AT 0�! INSURAMCE ON FILE WITH SJLHD? YES_ <br /> "TYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK S SEWER LINES PIT PRIVY o <br /> SEWAGE DLSP SAL,FIELD " CESL/SEEPGE IP T THER <br /> PROPERTY LINE p PRIVA�ESTIC WELL la'L— PUBL D MESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECJFICATIONS <br /> Industrial Cable Tool Dia. of Wellr Excavation U <br /> Domestic/private Drilled Dia. of Well Casing -- <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection =Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed y: �.P <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. <br /> PUMP REPLACEMENT: P State Work Done <br /> PUMP REPAIR: '❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter �` /(c-e _ Approximate Depth <br /> Describe Materia anProcedure' <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 ,#at Aq`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. _ �y <br /> SIGNED . TITLE: () '1� DATE: �' �' � 197 7 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FQR DJFARTMENT USE ONLY <br /> PHASE I <br /> TP—PLICATION ACCEPTED BY DATAr7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3- -2-4- ? <br /> G <br /> EH 1426 Rev. 12-77 2M <br />