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SAN JOAQUIN LOCAL HEALTH DISI'RICT <br /> F�61�FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. IN <br /> ` Telephone: —MUST 466-6781 - r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued "71(0 ` <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Tri pl i;cate <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. k2z -� <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name "' phone <br /> Address n4VCity <br /> Contractor's Name License# Phone (� <br /> IS CERTIFICATE OF WORKMAN'S COM PENSA 0`! INSURANCE ON FILE WITH SJLHD? YES 1' NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION[j <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER ❑ � <br /> PUMP INSTALLATION M 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 SPECIFI NS <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 <br /> Cathodic Protection p .Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 becomesub ' to Workman's Compensation <br /> laws of a ifornia. " :. <br /> I WILL CAL F R A GROUT INSPEC N ,PRIOR TO GROUTING A A F L SPE O <br /> SIGNED TITLE: DATE• �/n7 <br /> DR W PL T <br /> PLTN-- ON REVS DE <br /> FOR DEPARTMENTe ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> -4z=z2tn <br /> PHASE II GROUT INS CTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ,. <br /> EH 1426 Rev. 12-77 -- -- -_ C � 1/78 2M <br />