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SAN JOAQUINc1,OGAL HEALTH DISTRICT , <br /> + FFICE USE: 1601 E. Hazelton Ave.;; Stockton, CA 95205 Permit No.,7g_yjt/g <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRllCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires I Year From, Date Issued <br /> Complete In Trip icate ; <br /> Application is hereby made to the San Joaquin Local Health District for a perm <br /> and/or iit to construct <br /> nstall the herein described. This application is made in compliance with San <br /> ,oanuin CountyOrdinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET 'ADDRESS , CITY/TOWN <br /> Owner's Name .4TP-���� Phon <br /> Address <br /> City <br /> Contractor's Name LicensesPhone y ! <br /> IS CERTIFICATE OF WORKMAN"S COMPENSATION INSURANCE N FILE WITH SJLHD? YES �� NO <br /> TYPE OF WORK (Check) : NEW WELLE9 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLI)RINATION Q WELL ABANDONMENT❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR Cp PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ---- <br /> SEWAGE DISPOSAL FIELD / C S OL/SEEPAGE PIT OTHER <br /> PROPERTY LINVA PRIVATE—DO WELL 4�� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 na — <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 Materia an Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accorda <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Loc <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 OUT SNS ION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE: DATE: <br /> DR W PLOT PL N ON REVERS E <br />'HASE I FOR DEPARTMENT dSE ONLY <br /> APPLICATION ACCEPTED BY DATE 1.2417e <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY ,e- DATE INSPECTION BY DATE j� <br /> ��7� <br />:H 1426 Rev. 12-77 1/78 2M <br />