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SAN JOAQUIN :LOCAL HEALTH DISTRICT � <br /> FFICE USE: '✓ 1601 E. Hazelton Ave. , Stockton CA 95205 Permit - <br /> No. 6 / u <br /> 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 custruct <br /> and/or install the work herein described: This application is made in compliance with San } <br /> ,oaQuin County Ordinance 14o.' 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT, STREET ADDRESS / ® Y 7— R CITY/TOWN-40,P (� <br /> Owner's Name Phone <br /> Address 41 <br /> Cit —` <br /> y_Y.r'ccar - <br /> Contractor's Name ' ,✓� F- � 11cense Phone 4'? <br /> IS "CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE Odd .-FILE" WITH SJLHD?-- YES` ` N-0 <br /> TYPE; OF WORK (Check.).: _NEW WELLsEr::---DEEPEN.02, 4RECDN'DITI-ON 0 "DESTRUCT I _ _ON' , - ---� <br /> WELL,CHLO.RINATTON''p`�.W LL ABANDONMENT 0 OTHER 0 � <br /> PUMP�INS.TAL'-LATION_•� PUMP ' 'REPAIR❑ PUMP REPLACEMENT ❑ G <br /> DISTANCE TO NEAREST: SEPTIC TANK 7G5--SEWER. LINES ?S---)OL PIT PRIVY t> <br /> SEWAGE DISPOSAL FIELD_._ CESSPOOL/SEEPAGE PIT OTHER � <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED' USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> X X `' ` Cable Tool Dia. of Wel.} Excavation ► �� <br /> Domestic/private Drilled Dia. of Well Casing' �� .r <br /> Domestic/public Driven, Gauge 'of Casing -- _ <br /> Irrigation s, .S Gravel-, Pack Depth of `Grout Seal <br /> Cathodic Protection x Rotary Type of Grout I <br /> Disposai'w .r Other Other -Information , <br /> :> yGeophysical -"Surface .Seal 'Installed b ., <br /> PUMP INSTALLATION:. Contractor <br /> Type of Pump H <br /> PUMP REPLACEMENT': ❑State Work Done, <� <br /> PUMP REPAIR: []State Work Done <br /> DESTRUCT ION-OF-WEL-L- We11 Diameter - = <br /> ,. - <br /> Describe Materia and Procedure <br /> ApproximateYDelsth .__` <br /> 41 <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 CALL F R A::GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED .TITLE: DATE: <br /> � --��' <br /> .(DRAW LOT, P,L N ON- REVERSE SIDE . + <br /> 1 HASE I 3p, J FOR DEPARTMENT USE ONLY <br /> ... �, _. <br /> VPPLICATION ACCEPTED' BY <br /> ell DATE <br />%DDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III 4INAL INSPECTION <br />;NSPECTION BY DATE 2 INSPECTION BY DATE J <br />:H 1426 _Rev. 12-77 <br />