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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQR, Q4ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit 'No.2�?--L 3,4/44 <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 /> ,'oanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin. Local Health <br /> District. <br /> EXACT STREET ADDRESS 46 /✓ CITY/TOWN 4,24 4Z4t1 .. <br /> Owner' s Name _ ,� `d�. r, ._ �. Phone <br /> Address {�. a/ Ci ty <br /> Contractor's Name License#/fa -7�s'Phone z- <br /> IS CERTIFICATE OF WORKMAN'S rnmPEN IO"J INSURANCE ON FILE WITH SJLHD? YES ,C NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ rc <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT EN <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 C <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 , 0-01 <br /> Type of PumpH.P. IT <br /> PUMP REPLACEMENT: C9State Work Done + . ' . ; 0 e&t �/ ,j'�, 4. AM e' ,r, <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 A GROUT INSPECTIO I R ROUTING AND A FINAL INSPECTION. <br /> SIGNED DATE:. A>Znt <br /> MRAW PL L N ON/REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE c�IW-2, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E II ' FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 Rev. 12-77 1/78 . 2M <br />