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rt- 5AN JUAQUiN LUUAL,HEAL I N UlJ I Kl1,I <br /> FFICE US£:1 .fi 1601 E. Hazelton •ve.= Stockton CA <br /> i � � �, 95205 Permit No. r-/ , <br /> Telephone: -(209) 466-6781 <br /> Date Issued_ _ -7e <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT -// 7 -- <br /> a <br /> I This Permit Expires 1 Year- From Date Issued <br /> Complete In Triplicate <br /> I <br /> Application is hereby made to the San Joaquin Local Health, Distr.ict .for..a permit to construct I <br /> and/or .install the work herein described. This application is made ,in compliance with San <br /> k.oaquin County Ordinance No. 1862 and. the Rules and Regulations of ,the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS <br /> CITY/TOWN <br /> Owner's Name Phone a <br /> Address &A. City_ t�r��«, , ...,,.,,.._— <br /> Contractor's Namea <br /> Li cense PhoneiS�-- yZ " <br /> _'S CERTIFICATE OF 'WORKMAN'S 011PENSATION I"JSURAIN ON FILE WITH SJLHD? YES I10 <br /> -TYPE OF WORK (Check) : NEW WELI4 DEEPEN ❑ RECONDITION ❑ DESTRUCTION[] <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION C1 PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TAN / SEWER LINES / PIT PRIVY �-.. <br /> SWAGE DISPOS Lf IELD f CESSPOOL/SE£PIGE PIT OTHER --- : <br /> PROPERTY LINVO-#PRI VATE OM STIC WELL 1113 PUBLIC DOMESTIC WELL p <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS J <br /> Industrial Cable Tool Dia, of Well Excavation c!1 <br /> 'Domestic/private Drilled Dia, of Well Casing <br /> omestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seale <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geo h sical <br /> p y Surface Seal Instal_ ed by: _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 4 <br /> Approximate Depth <br /> Describe Material and Procedure = - <br /> _ I <br /> I hereby certify that I have prepared this application and that the work will',be done in accordancf' <br /> with;San Joaquin County Ordinances , State Laws`, and Rules and Regulations of t}ie 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 shale <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California " -_--.. .. <br /> I .WILL CALL . <br /> A GRO ECT PRIOR B.OUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> R W PLOT PLAN ON-REVER IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 11171701:11- <br /> ADDITIONAL COMMENTS: ` <br /> PHA II GROUT INSPECTION PHASE I U ,FINAL INSPECTION <br /> INSPECTION BY <br /> DATE 1 /U INSPECTION B r DATE/ /If <br /> II <br /> f <br />.H_ 1426 Rev. Z2-77 f. Q <br />