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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 G` <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 /> Arid/or install the work herein .described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules. arpd- Re u ations of the San Joaquin Local Health <br /> ,;strict. L.Q?` A4&e � <br /> EXACT STREET ADDRESS /3 1 OZAI r4 G7F_� e r,(J/tITY/TOWN <br /> Owner's Name ^ ° Q ,b Phone <br /> Address r City <br /> Contractor's Name ` License$ Phone.14:� 9 e1_/, _ <br /> TS CERTIFICATE OF WORKMAN'S COFIPENSATIO'N INSURANCE ON FILE WITH SJLHD? YES t NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION ❑ DESTRUCTION F1 <br /> WELL CHLORINATION p WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION Za- -%MP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK 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.---Mmestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection L--�otary • `Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: .110 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump r H.P Zr <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑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 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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:— <br /> (DRAW <br /> ATE:DR W 'PLOT PLTNT ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED •BY DATE <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� `, 1/78 2M , <br />