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SAN JUAQU I N LUCAL :HLAL f H DI S I X1 C;I y <br /> Y FFICE USE: 1601 E.- Hazelton .Ave. , Stockton, CA 95205 Permit No. <br /> Telephoner (209) 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued S <br /> This Permit Ex ires -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 ADDRESS CITY/TOWN <br /> Owner's Name Phone �6 6 Z <br /> .� <br /> LJ <br /> Address ` <br /> Al City <br /> Contractor's Name &eu Zzz 6 1 cense Phone� �_���� <br /> i <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO I <br /> TYPE OF WORK (Check) : NEW WELM DEEPEN 0 '- RECONDITION ❑ DESTRUCTION M <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 i <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT C] <br /> DISTANCE TO NEAREST: SEPTIC TANK /v O4- SEWER LINES ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELDjad - CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE •TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ___.ZCab1e Tool „Dia. of Well Excavation Z,2 I/ <br /> Domestic/private Drilled Dia. of Well Casing. �> <br /> Domestic/public .x Drived— -.` Gauge of Casing � <br /> Irrigation Gravel Pack Depth of Grout Seal 4� <br /> Cathodic Protection Rotary IT,ype of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal- Installed b : — �fi <br /> TRUMP-1-NSTALLATION: Contractor ' Y <br /> Type of Pump H. . <br /> PUMP REPLACEMENT: ❑State Work Done r% <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ° <br /> 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 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 POUT I P UTI RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: ,��,� DATE: <br /> D W P T L N ON REVERSE" 'IDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> :. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: --- - <br /> PHASE II GROUT._INSPECTION. PHASEAJIU FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE )9� <br /> EH 1426' `Rev. 12M77 - 1 t71AAM <br />