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,.. _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> g : fFFICE 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 Triplicate <br /> Application is hereby made to the San Joaquin -Local Health District for a permit to construct <br /> land/or install the work herein described. This- application is made Tn compliance with San <br /> juloaqui o County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local 'Health <br /> D i s t r;c t. a / E 4 /7:t` •: .z-147— 02' AD—4( <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner' s Name Phoned-7 <br /> Address ' City <br /> Contractor's Name L'cense# Phone / <br /> -moo ����&� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION I�ISURA' E ON FILE WITH SJLHD? YES—k— NO <br /> TYPE OF WORK (Check) : NEW WELLC DEEPEN 0 RECONDITION ❑ DESTRUCTION[ <br /> WELL CHL O INATION 0 WELL ABANDONMENT Q OTHER 0 h- <br /> PUMP INSTALLATION [I PUMP REPAIR❑ PUMP REPLACEMENT ❑ C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' <br /> i 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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> . `Irrigation _y .Gravel Pack Depth of Grout Seal <br /> Cathodic Protection __)(_Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: — <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: Q State Work Done <br />, DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ana 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 CALL FOR A GROUT PECTION PRIOR TO GROUTING AND A FI AL INSPECTION. <br /> SIGNED I <br /> . TITLE: DATE: l <br /> R W PL T PLAX ON REVERE ID <br />'i PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -y-Y, DATE <br />', ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL FNSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7/3d/7,5; <br /> 67 <br /> 1EH 1426 Rev. 12-'77 _ ►-,Q �,� <br />