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JAN JUAQUIN LUGAL HtALIh UiJIKl(11 <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 <br /> Telephone: (209) 466-6781 <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 /> U'oanuin County Ordinance No. 1862 and the Rules and Regulations of the S a n Jopq .nocal Health <br /> District. ) `� f ) �,ef <br /> EXACT STREET ADDRESSoWee ( AV V10rtl , , -4? b CITY/TOWN Aer <br /> Owner' s Name 90D rIPhone <br /> Address City <br /> Contractor's Name Licensed Phone �� l <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSU 510E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL C�—' DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHERI-I <br /> PUMP INSTALLATION Rr- PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK /eP SEWER LINES,&W'�'P—IT PRIVY <br /> SEWAGE DISPOSAL FIELD — CESSPOOL/SEEPAGE PITT/<p fiOTHER <br /> PROPERTY LINEApPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ndustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private _Drilled Dia. of Well Casing i <br /> Domestic/public Driven - Gauge of Casing 1� <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 ,� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑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 CALL FOR & GRWJ I CTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED _ rr rl F• /--- DATE: <br /> (T)RAWPLOT PLTN ON REVERSE DE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE f /Z-78' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY )j;� DATE INSPECTION BY�� DATE \Z Q_ <br /> EH 1426 Rev. 12-77 1/78 2M <br />