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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICEUS : 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> �Z - <br /> Telephone: (209) 466-6781 <br /> 2t/-zAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued .3 <br /> This Permit Expires 1 Year From Date Issued <br /> Complete I n T-r-17 TER e ' <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// �zX ! L /./� CITY/TOWN,�7-©ekP <br /> Name � � 42 44 - Phone <br /> Owner's Nam ' /-�,�5' <br /> Address ' �7 1 .�"� /P �/1� --- ty <br /> Contractor's NameiL enseF Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTIONS,. <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER F-3 <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0 PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES/e O PIT PRIVY <br /> SEWAGE DISPOSAL FIELD C SE SPL/SEEPAGE PT1 — OTHER <br /> PROPERTY LINE -. PRIVATE D MESTIC WELL PUBLIC D MESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Caere 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 Sea <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. . <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter (� sr Approximate Depth ,r::f 0 � <br /> Describe Material and Procedure ve To -0 <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 A GROUT INSPE TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: 6 ti DATE: <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> PPLIC TION ACCEPTED BY 9ATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BYSbZ,, I DATE INSPECTION BY Y DATE <br /> EH 1426 Rev. 12-77 , 1/78' 2M <br />