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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> _29-- 9 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /y-,3-,2g' <br /> This Permit Ex ires 1 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 4v V ,(/ 6 CITY/TOWN <br /> Owner's Name Phone 3 6r <br /> Address . e City . <br /> Contractor' s Name License#/f ZL6 Phone - <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"! INSURAINCE ON FILE WITH SJLHD? YES—Z— M40 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION (] DESTRUCTION❑ <br /> WELL CHLO INATION Q WELL ABANDONMENT ED OTHER 0 � <br /> PUMP INSTALLATIONUMP REPAIRE] PUMP REPLACEMENT Q W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _Domestic/private _Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing o K7 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor � a- e <br /> ff <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an-d 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 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 /> (DRAW PLO—T--PL-TN- ON REVERSE SIDE <br /> FOR DEPARTMENT-,USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I Fd AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> EL1426 Rey- 12-77 GC> 1/78 2M <br />