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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.��1 <br /> Telephone: (209) 466-6781 <br /> r Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (complete In Triplicate) <br /> Acation is hereby!made to the San Joaquin Local Health District for a permit to construct <br /> an /or <br /> 4install 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 . L Z. CITY/TOWN <br /> 'Sj�'�=' �� <br /> Owner's Name F- t= Phone �3/ Ir 7 <br /> Address .. . s �-/ L, - ��/, Cit '.l `� 1 <br /> Contractor's Name y '�i� C f 7-17 Li cense# '' �.3 Phone' f� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES N0 <br /> TYPE OF WORK (Check) : NEW WELL M" DEEPEN EJ RECONDITION Q DESTRUCTION.[, <br /> WELL CHLORINATION Q WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION M-' PUMP REPAIR Q PUMP REPLACEMENT Q g$. <br /> DISTANCE TO NEAREST: SEPTIC TANK '7e` '�_SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL IELD CESSP L/SEEPAGEPST OTHER <br /> PROPERTY LINE - PRIVATE D ESTIC WELL _ PUBLIC D MESTIC WELL <br /> INTENDED USE TYPE OF WELL. s CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We 11 Excav tia on ` <br /> —7`-Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic ProtectionY Rotary Type of Grout 77Z-7 <br /> `—,``/ - f <br /> Disposal Other Other Information <br /> GeophysicalSurface Seal Installed by: 77777 <br /> D <br /> PUMP INSTALLATION: Contractor • 'TIS <br /> Type of Pump FZ7C <br /> PUMP REPLACEMENT: <br /> Mate Work Don <br /> e <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 andthatthe work will be done in accordan <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. " 44 <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 3 <br /> (DRAW L L N ON REVERS SI <br /> PHASE I R DEP RTMEN USE ONLY <br /> APPLICATION ACCEPTED BY DATE �-a3 <br /> ADDITIONAL COMMENTS: <br /> P AS kG—ROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE -ay'I INSP ' 3-�9 <br /> ECTION BY DATE � � <br /> EH 14 26 Rev. 78 9/78 2M <br />