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SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7- 6- <br /> (Complete In Tripl'i'cate)'' <br /> Application is hereby made to the San Joaquin Local. Health.,District�-for a'--permit toconstructand/or install the work herein described. This a-pplication. is made :in .compliance- with San •g <br /> Joaquin County Ordinance No. 1862 and the Rules and Regdlations of the San Joaquin Local Health <br /> District'. �.. . _ <br /> EXACT- STREET ADDRESS OWNS .. <br /> Owner's Name Pt Phone 4 <br /> Address <br /> -- City . ,. <br /> Contractor' s Name . Li cense, y ° Phone g� ��,f I <br /> i If441Z <br /> SIS CERTIFICATE OF wnPK"1AN'S C0111PENSATION INSURANCE ON FILE 'WITH�SJLHD? YES 0 <br /> TYPE OF WORK (Check) : NEW WELLS DEEPEN Q RECONDITION [3 DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT ® OTHER 0 � <br /> PUMP INSTALLATION E] PUMP REPAIR 0, PUMP REPLACEMENT El <br /> DISTANCE TO. NEAREST-:.. SEPTIC TANK- <br /> - SEWER LINES G f' PIT PRIVY, o <br /> t SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE .PIT m. <br /> - OTHER . <br /> ' PROPERTY LINE - _PRIVATE�DOMEST1-c WELL .- PUBLIC DOMESTIC WELL <br /> € ­J NTENDED USES TYPE OF.WELL a CONSTRUCTION SPECIFICATIONS <br /> I Industrial Cable Tool Dia, of WeTT Excavation ' <br /> Domestic/private _ Drilled Dia, of Well Casing i <br /> Domestic/public . Driven Gauge of Casing j <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> — athodic Protection `Rotary Type of Grout <br /> Disposal <br /> Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. # <br /> PUMP 'REP,`ACEMENT: []State Work Done <br /> PUMP REPAIR: : Q State Work Done <br /> DESTRUCTION OF WELL: ' Well Diameter Approximate Depth <br /> Describe Materia and Procedure <br /> y <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 's`ignature 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 INSPECTION PRIOR TO GROUTING AND A FINAL- INSPECTION. <br /> SIGNED TITLE: DATE: -�-- y <br /> DR W PLOT PL N ON REVERSE SIDE <br /> PHASE I OR DEPARTMEN T USE ONLY <br /> APPLICATION ACCEPTED DATE �' <br /> ADDITIONAL COMMENTS: <br /> i <br /> PHASE I GROUT INSPECTION PHASE T FINAL INSPECTION <br /> INSPECTION BY DATE -z,� P� <br /> INSPECTION 8Y ---- DATE =3/``� <br />.H <br /> 14 26 Rev. 9/78 s. .(0/78 2M <br />