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SRN JUAQU 1 N LOCAL HMrAL l H D 15 f Ft l(;I ---•-�----�-- <br /> EOB FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permito.; $f <br /> Telephone: {209} 466-6781 <br /> "Yf APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �6�? <br /> This Permit Expires 1 Year From Date Issued'' <br /> D 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. r <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner' s Name Phone <br /> Address City <br /> Contractor's Name, License# Q&3 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL EP DEEPEN Cf RECONDITION Q DESTRUCTION EJ <br /> WELL CHLORINATION. p WELL._ABANDONME.NT Q_,_.,,,OTHER ' <br /> PUMP INSTALLATION Q PUMP REPAIR p PUMP REPLACEMENT E3 <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 SPECIFI <br /> Industrial Cable 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 -Seal G� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal . Other Other Information: <br /> Geophysical Surface Seal Instal ed <br />, PUMP INSTALLATION: Contractors <br />'E Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done f <br /> PUMP REPAIR: + Q State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r Describe Material an2 Procedure <br /> t <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,- <br /> ounty 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 becom Workman's Compensation <br /> laws of Califon a." <br /> I WILL CALL FO A G UT -INSPECTI PRIOR 'TO GRO ING AND A FINAL 'NSPC ION <br /> SIGNED TITL .en DATE: <br /> DR W PLT PLAN 71 <br /> ON REVE - ° <br /> FOR DEPARTMENT LY <br /> PHASE I <br /> i APPLICATION-ACCEPTED BY Y(.fC/ �. .. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IL GROUT INSPECTION PHASE MI FINAL INSPECTION <br /> iINSPECTION BY DATE INS ION BY ATE <br /> �!a'� 79 by"I J rx-vyTo-n �Fq.W <br /> 2M <br /> ,� 1/78 <br />