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F ICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ��- 7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ,/—/3- 7, <br /> This Permit Ex ire,. 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 <br /> 1-'We A" /`CITY/TOWN <br /> Owner' s Name <br /> Address s"`e,3 e _ <br /> Phone <br /> City <br /> Contractor's Name License# tg� 7 i�hone <br /> IS CERTIFICATE OF WORKMAN'S COMPEN TI "! INSURANCE ON FILE LIT � <br /> TFI SJLHD. YES fJ0 <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN ❑ RECONDITION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT DESTRUCTION❑ <br /> PUMP INSTALLATION � OTHER ❑ -- <br /> ❑ PUMP REPAIR m PUMP REPLACEMENT ❑ ' <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWAGE DISPOSAL FIELDER LINECESSPOOL/SEEPAGES PIT YIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool CONSTRUCTION SPECIFICATIONS <br /> ________Domestic/private Dia, of Well Excavation <br /> __Domestic/public Drilled Dia. of Well Casing <br /> _Irrigation Driven - Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary <br /> Disposal Other Type of Grout <br /> _Geophysical Other Information <br /> Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �- / �` <br /> PUMP REPLACEMENT: H.P. 3 d <br /> ❑State Work Done <br /> PUMP REPAIR: 12 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> � f f <br /> Describe Mater-ldl and Procedure Approximate Depth <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 Joa uin cal <br /> Health District. Home owner or licensed agent's signature certifies the following: q Local <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 />[ WILL CALL OR A GROUT INSPECT P I,OR` GROUTING AND A FINAL INSPECTION. <br />>IGNED � <br /> TLE: DATE: <br /> D W L PL ON REVERSE SIDE <br />'HASE I FOR DEPARTMENT USE ONLY <br /> PP CLI ATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> VSPECTION BY DATE TVq?;MW <br /> INSPECTION <br /> 1 1426 Rev. 12-77 <br />