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SAN JOAQU_IN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. ; Stockton, CA 95205 Permit No.-7, /� <br />! <br /> -Telephone: (209) 4.66-6781 <br /> t <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires I Year From Date Issued <br /> r. Complete ,In Triplicate <br /> Application is hereby made to the San Joaquin Local Heal'th. District for a permit to construct <br /> and/or install the` work herein described. This application is made in Compliance with San <br />'-,oanuin County Crdinance No. 1862 and the Rules and Regulations of .the San Joaquin Local Health <br /> D,i 5tr�ct. <br /> EXACT STREET ADDRESS to`��] CITY/TOWN_ (.- Q/D.-[ <br /> Owner' s Name [, Phone <br /> jAddress r - <br /> City. <br />,' Contractor's Name R LicensQ Phone <br /> IS CERTIFICATE OF WORKMAN'S CbMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) :. NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ NJ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION [PUMP 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 /> �mestic/private Drilled - Dia. of Well Casing <br /> D mestic/public Driven - Gauge of Casing <br /> v-Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal her Other Information <br /> Geophysical Surface Se Installed by: <br /> PUMP INSTALLATION: Contractor Y � ���' <br /> Type o 'P ! H. <br /> PUMP, REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: t <br /> ❑State Work Done <br /> DESTRUCTION--OF- WELL: Well Diameter * ..ti ; <br /> •Approximate Depth� .�.�._..,.� <br /> Describe Material and Procedure <br /> I hereby certify t y 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 )OR A GROUT INSPEC7I RIOR 0 GROUTING AND FINAL INSPECTION. i <br /> SIGNED /., _ - TITLE: DATE �� I <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY___ WA DATE �' 79 611 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION <br />:H 1426 Rev- ' 12-'77' <br />