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SAN JOAQUIN LUCAL HEALTH UISTRICT <br /> MFFICE 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 <br /> This Permit- Expires 1 Year .From Date Issued . <br /> Complete In Tri pl irate <br /> E Application is hereby made to the San Joaquin Local Health Djstrict for a permit to construct <br /> j 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. � ��L3 <br /> EXACT STREET ADDRESS = 612 CITY/TOWN <br /> Owner's Name Phone S' <br /> Address ,4 <br /> z <br /> Cjty <br /> Contractor's Name Licensees 4 Phone S{L2-,7f/h <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO11 INSURA?IC ,OP1 FILE WITH SJLHD? YES NO" <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION M PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK,122+ SEWER -LINES PIT PRIVY �-- <br /> SEWAGE DISPOSAL, FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINLd -(PRIVATE DOMESTIC WELL-/&2Z— 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 1 <br /> Domestic/public ., Driven Gauge of Casing <br /> Irrigation —Gravel Pack Depth of Grout Sea Z) / <br /> $ <br /> Cathodic ,Protection _Rotary Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal Installed b : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work ,Done <br /> PUMP REPAIR: QSttaat5 Wor DO e t . <br /> DESTRUCTION OF WELLlWefl� Diameter r <br /> Approximate Depth <br /> Describe Materia an 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-C L FOR A GROUT P TI P IOR TO GROUTING AND A FINAL INSPECTION. <br />:SIGNED _ TITLE: DATE: <br /> W PLT L N ON REV SIDE <br /> PHASE- 1 <br /> F R DEP RTMEN USE ONLY <br /> � I <br /> APPLICATION ACCEPTED BY DATE X1-7 <br /> ADDITIONAL COMMENTS: <br /> P E F GROUT INSPECTION PHASE III L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE EH 7 <br /> a Cl <br /> 1426 Rev. 12-77 <br />