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SAN J01�)UIN,, :OCAL 'HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazel ton -Ave. , Stockton, CA 95205 Permit. Na.'7S—/6S"S7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - o- <br /> This Permit Expires I 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 /> 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. <br /> EXACT STREET ADDRESS LA CITY/TOWN r- . <br /> Owner's Name . _ Phoned -� <br /> Address - City —_r <br /> Contractor' s Name License#1ct` Sh p Phan <br /> IS CERTIFICATE OF WORKMAN'S COFiPENSATiO'N INSURANCE ON FILE U TH SJLHD? YE NO <br /> TYPE OF WORK (Check) : NEW WELL,] DEEPEN F-1 RECONDIT ON DES � <br /> WELL CHLORINATION Q WELL ABAND NMEN <br /> PUMP INSTALLATION PUMP REPA R[� [4 <br /> R AT—WENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ReN P Y <br /> SEWAGE DISPOSAL FIELD CESSP /SE PIATOTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUB . DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUC SPECIFICATIONS <br /> Industrial Cable Tool Dia. of rEtion <br /> omestic/private Drilled Dia. ofDomestic/public Driven Gauge ofIrrigation Gravel Pack th ofCathodic Protection Rotary Typ CQ <br /> Disposal Other Oth formation <br /> Geophysical r e Seal Installed by: <br /> PUMP INSTALLATION: Contractor Csa <br /> Type of Pump H.P. <br />(` PUMP REPLACEMENT: F] State Work Done <br />(', PUMP REPAIR: ❑State Work Done <br /> r 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 /> f "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 /> DR W PLOT PLAN ON REVERSE DE <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 /> 1 1'74' Om <br />