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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF}►CE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> Telephone.: .F. (209) 466-6781 <br /> _ Date Issued <br /> APPLICATION C TI1N FSR WELL CONSTRUCTION OR SUMP PERMIT <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. w <br /> EXACT STREET ADDRESS CITY/TOWN- <br /> Owner's <br /> Y/TOWN-Owner's Name _ Phoneg�.3 —6j5 �:Z <br /> Address City <br /> Contractor's Name License#39.5 7_ty— Phone ,T 3 95--K <br /> IS CERTIFICATE OF WORK11AN'S COMPENSATION INSURA"NCE ON FILE WIVE SJLHD? YES NO. <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION <br /> 0 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ - PUMP REPLACEMENT w <br /> R <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 5 <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC. D MESTIC WELL <br /> INTENDED USE TYPE OF_WELL_, CONSTRUCTION SP.ECIFICATI'ONS <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 Sea <br /> _Cathodic Protection Rotary Type of Grout Y <br /> �' Disposal Other Other Information <br /> k ._ Geophysical <br /> Surface Seal Installed TT <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _—H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> UlP REPAIR: _ ❑State Work Done _ Y,t <br /> DESTRUCTION OF WELL: Well Diameter ApproximateDepth <br /> t <br /> Describe Mater'ial and Procedure <br />' I hereby certify that I have prepared this application and that the work will be done in accordant <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 /> DR W .PL <br /> PLAN ON REVERSE SI E <br /> 3 <br /> FOR DEPARTMENT USE ONLY <br />'PHASE I r <br /> APPLICATION ACCEPTED BY DATE — --Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINA INSPECTION <br />;INSPECTION BY DATE INSPECTION BY DATE <br /> EH 14 26 Rev. 9/78 n7 6 9/78 <br />