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SAN JOAQUIN LOCAL HEALTH UISIRICI <br /> rFOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> /V d-6- d,;3 a 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 3,4 coy Ts 14,4 d CITY/TOWN <br /> Owner's Name_4,y L, ,Q g 1��J,, Phone_ <br /> Address City <br /> Contractor's Name AwEi e Z-j)z11 ///"yo Zn c Li cense# R3?//Yz Phone Vy_ -2 '/G <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE/6`h RIVATE DOMESTIC WELL&� 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 -.h� /},pS-r /�1/�' <br /> Irrigation Gravel Pack Depth of Grout Seal _S�fo <br /> Cathodic Protection Rotary Type of Groutffry ,Z£ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: ["� a Z&,c e <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 CAFORA ROUT T PRIOR TO GROUTING AND A FINAL INSPECTION. , <br /> SIGNED TITLE: DATE: <br /> DR W PLOT PLAN ON REVER DE <br /> FOR EP RTMENT USE ONLY <br /> PHASE I � J <br /> APPLICATION ACCEPTED BY , DATE e 1-7e <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY,,4/ - DATE _ INSPECTION BY" DATE ' <br /> EH 1426 Rev. 12-77 1/78 2M <br />