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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 _,IY <br /> Telephane: X209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (CoEnplete . 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. 1.862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS OJ22�_p 2 '4 C 44-�. CITY/TOWN S�cc <br /> Owner's Name Phone �� 2. •— 7?Z 3 <br /> —. . . <br /> Address � �' _ � „�, <br /> City S c _ <br /> Contractor's Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMIPENSATION INSURVlC ON FILE 1rlITH SJ�HD? YES � �- O <br /> TYPE OF WORK (Check) : NEW WELL M— DEEPEN ❑ RECONDITION ❑ DESTRUCTION[� <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ � <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LANES PIT PRIVY-" <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE15 PRIVAT D MESTIC WELL-Z.42— PUBLI D MESTIC <br /> INTENDED USE TYPE OF -WELL,. CONSTRUCTION SPECIFICATIONS { <br /> Industrial Cable Tool Dia. of Well Excavat1on /2 <br /> Domestic/private Drilled Dia, of Well Casing 4 .ft <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal ;CZ2 <br /> Cathodic Protection ��Rotary Type of Grout (� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instilled b :' <br /> PUMP INSTALLATION: Contractor pr <br /> Type of Pump <br /> POMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State .Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe MaterIaT and Procedure <br /> I 'hereby certify that I have prepared this application and that'the work will6be done in accordance <br /> 44th San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local ' <br /> iealth District. Home owner or licensed agent's signature certifies-the-,fcll-owing: <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 />[ WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE -DAT-E-:-- DATE-:- <br /> DR W OT L N ON RE RSE SIDE. <br />'RASE IR EPAR MENT U E ONLY — -- <br /> IPPLICATION ACCEPTED BYlip <br /> ADDITIONAL COMMENTS: DATE <br /> P ASE I GROUT INSPECTION PHAS II i=INAL INSPECTION <br /> NSPECTION BY DATE _�� INSPECTION BY DATE <br /> N 14 26 Rev. /78 9/78 2M <br />