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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE "USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7� <br /> Telephone: (209) 466-6781 <br /> .� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued �5 -1 r <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 fora permi.t' to construct <br /> and/or install the work herein described. This application is made in compliance with San ' <br /> 'oaouin County Ordinance No. 1862 and- the Rules and Regulations of the San Joaquin Local. Health <br /> District. F ; <br /> EXACT. STREET ADDRESSCITY/TOWN <br /> Owner's Name e4nnw.m , <br /> Phone <br /> Address , — .1rCi ty . <br /> Contractor's Name ' 9N <br /> V ZA,, x License# Z Phone "tom <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA"dCE ON FILE WITH SJLHD? YES _ t4 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION ® DESTRUCTIONED <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER( <br /> PUMP INSTALLATION PUMP REPAIR p PUMP REPLACEMENT C] <br /> DISTANCE TO'NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> I <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL -- ! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION.+SPECIFICATIONS <br /> f -- <br /> Industrial Cable Tool ,Mia. of Well-Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gaugelof Casing ` <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout , " <br /> Disposal Other Other Information _e <br /> Geophysical Surface Seal Installed`-by: <br /> PUMP I.NSTALLAT!ON: ' ` ' Contractors ., s� . <br /> Type of Pump H.P. <br />'PUMP REPLACEMENT: []State Work Done - <br /> . <br /> PUMP REPAIR: QState 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 /> "1 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',s.ubject to Workman's Compensation <br /> laws of California. " s <br /> 1 WILL CALL_FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ` . TITLE DATE: <br /> _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY' <br />-PHASE I <br /> APPLICATI-ON ACCEPTED BY 'f DATE��"������ <br /> ADDITIONAL COMMENTS: <br /> PHASE II, GROUT INSPECTION PHASE III F NAL INSPECTION <br />.INSPECTION BY ; i.. DATE INSPECTION BY DATE <br />-EH 1426 Rev. 12=77 <br /> 1/7$ <br />