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SAN JOAQUIN LACALJ EALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. -//,3 o- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued,,/,;;t S=/d ' ' <br /> (Colnplete In Triplicate) pct CGr /�' , <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 " CITY/TOWN: <br /> Owner's Name Phone <br /> Address <br /> Contractor's Name Li cense#Kj,74!SL Phone r <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSUR 110E ON FILE WITH SJLHD? YES NO' <br /> TYPE OF WORK (Check) : NEW "WELLM DEEPEN 0 RECONDITION-Co, DESTRUCTION[l <br /> WELL CHL0 INATION 0 WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENTC� <br /> V <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Ia��� PIT PRIVY -- <br /> SEWAGE DISPOS&IELDfZ�OI- I CESSPOOL/SEEPAGE PIT --,.OTHER <br /> PROPERTY LINE/df PRIVATE�DORESTIC WELL -,'2�' PUBLIC D6RESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION .SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing A �+ +j <br /> Domestic/public Driven Gauge of Casing 4 <br /> Irrigation Gravel Pack Depth of Grout Sea , <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal Other Other Information <br /> ' Geophysical Surface Seal Insta e b : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: C]State Work Done <br /> PUMP REPAIR: O State Work Done <br /> DESTRUCTION_OF'WELL: Well Diameter Approximate- Depth <br /> Describe Materia an rote ure <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 CaTifornia. " ' <br /> I WILL CALL FOR OU SP -ION PRIORTO GROUTING AND A FINAL INSPECTION. , <br /> SIGNED TITLE: - DATE:,5 Z)Xc <br /> PL L N ON REVER E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> . n DATE- ��z -- $- <br /> ADDITIONALCOMMENTS : <br /> PHASE GROUT INSPECTION. n PHASE III INAL INSPECTION <br /> INSPECTION BY ATE f 2./,X1''7 � � ­JXr"F S y-'-�. ___ <br /> ,�/�_ j INSPECTION B ® � DATE / � 7( <br /> EH 14..26 Rev. 9/78 ZVI),,-, 7 J1 v n..- . � � <br />