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' SAN JOAQUIN LOCAL HEALTH DISTRICT —FOR--OFFICEUSE: 1601 E. Hazelton Ade. , Stockton, CA 95205 Permit No. 78-/6 8Q Telephone: {209) 466-6781 Date Issued APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT This. Permit Expires 1 Year From Date Issued Complete In Triplicate Application is hereby made to the San Joaquin Local Health District for a permit to- construct ` and/or install the work - herein described. This application is made in compliance with San + Joaquin County Ordinance N 1862 and the Rules and Regulations of the San Joaquin Local Health District. &4( EXACT STREET ADDRESS C b T,- CITY/TOWN f CAe- Owner's Name �a Phone Address 415A.It City Contractor' s Name -t Li cense# o Phone3 IS CERTIFICATE OF WORKMAN'S COMIPENSATIO1 INSURANCE ON FILE WITH SJLHD? YES NO � TYPE OF WORK (Check) : NEW WELi� DEEPEN ❑ RECONDITION ❑ DESTRCTION d WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER0 � PUMP INSTALLATION R PUMP REPAIR❑ PUMP REPLACEMENT C] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Industrial Cable Tool Dia. of Well Excavation e_ Domestic/private TiDri11ed Dia. of Well Casing t Domestic/public Driven Gauge of Casing Irrigation Gravel Pack Depth of Grout Seal Cathodic Protection Rotary Type of Grout o Disposal Other Other Information Geophysical Surface Sea] Installed by: PUMP' INSTALLATION: Contractor Type of Pump_�! H.P. I PUMP•REPLACEMENT: Q State Work Done „3 kPUMP REPAIR: ❑State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth { Describe Materia and Procedure I hereby certify .that I have prepared this application and that the work will be done in accordant with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local Health District. home owner or licensed agent' s signature certifies the following: 4 "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman' s Compensation laws of California." I WILL CALL FOR_A GPWT LNSPECTIO PRIOR TO GROUTING AND A FINAL ERS E INSPECTION. SIGNED � TITLE: DATE: � • W PL T PL N ON REV FOR _ EPARTMENT USE ONLY_ PHASE IC APPLICATION ACCEPTED BY DATE /- '� -- .' ADDITIONAL COMMENTS: 4 PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION INSPECTION BY DATE _-INSPECTION BY DATE - _ 1/78 �;