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r---------- 5AN JUAQUIN LULAL HtHL I M Ul.- I M I <br /> EOR, FFICE USE: 1601 E. Hazelton Ave. , 'Stockton, CA 95205 Permit No. —S <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued o?This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Anplication is hereby made to the San Joaquin Local Health District for a permit ,to construct <br /> anal/or install the work herein described. This application is made in compliance with San <br /> , oaquin 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 s 7 <br /> Address City <br /> Contractor's Name Licensee Phone (Q4: <br /> 'S CERTIFICATE OF WORKMAN'S COMPENSATION IiNSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL S DEEPEN 0 RECONDITION Q DESTRUCTION F1 <br /> WELL CHLORINATION 0 WELL ABANDONMENT O OTHER F-3 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT L] <br /> DISTANCE TO NEAREST: SEPTIC TANK05-ig 1 SEWER LINES PIT -PRIVY <br /> 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 /> ��_I)omestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing 13- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> - Cathodic Protection Rotary . -Type of Grout_(`, ��,, <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: 6,14ur4n3LSOI�j <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: r7 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 /> lawsof California. " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED n, TITLE: DATE: 12 <br /> DR W PLOT PLTNT ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 11/2 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 Rev. 12-77- 1/78 2M <br />