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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. -.-e <br /> �. Telephone: (209) 466-6781 16' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> 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 /> 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. <br /> EXACT STREET ApDRESS _ CITY/TOWNz" 9 <br /> Owners Name �� jsn�� Phone <br /> Address Ci tz <br /> y�� _ <br /> Contractor' s Name License Phone _Zola <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOM IMSURAmr E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Dd DEEPEN ❑ RECONDITION C] DESTRUCTION n -Z <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION C3 PUMP REPAIREI PUMP REPLACEMENT CJ <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINE If PIT PRIVY <br /> tA <br /> SEWAGE DISPOSAL�LFIELD / EE AGE PIT OTHER <br /> PROPERTY LIN 6-,h RIVA�STIC WELL5Q -F PUBLIC DOMESTIC WELL — <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ' <br /> _Irrigation -Gravel Pack Depth of Grout Sleal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information , ,,�,— ",Ow <br /> Geophysical Surface Seal Instal ed by: Ze <br /> e,�� <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 and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <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 CAL OR A GR UT INWECyffON AIR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: n DATE`S <br /> DRA PL T PL N ON REVE ID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY p DATE ,r-jl '7e <br /> ADDITIONAL COMMENTS: <br /> PHASE Il AOUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY D <br /> EH 1426 Rev. 12-77 <br /> 1/78 2M <br />