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a <br /> r SAN JOAQUIN •LOCAL;.RE-ALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave- Stockton, CA 95205 Permit No. 9- 3 a <br /> Telephone:: ,- 0209) 466-6.781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued j�-5-2 5� <br /> This. Perm?t,;Ex p i'res .1 „Ye'a' ,From :gate Issued <br /> .; , Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local. ,Hewl'.th• ,District .for -a permit tofconstruct <br /> and/or' ins�ta'll 'thelwol* !herein described. This -a•pplicattom.-is made-in ,compl.iance with San , - <br /> �oan ���County Oreinance�r� o': 01862 and the 1 Rules and .Regullat1on•s .of the. Sen, Joaqui.,n.; Local Health <br /> r'lstr'Ct. <br /> EXACT STREET AD RESS, �� [�.` CITY/TOW! . <br /> Owner' s Name �' � PhonesTn <br /> City <br /> Address .. . <br /> Contractor' s Name /t-? LicenseA D-3-'�S Phone ' 0_� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE OM FILE. WITH SJLHD? YES NO <br />` TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ - DESTRUCTION[D <br /> WELL CHLORINATION C] WELL ABANDONMENTED .OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR a. 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 SPECIFICATIONS <br /> Industrial Cable Tool rDia. of Well Excavation r. <br /> , Domestic/private Drilled,, Dia. of Well . Casing <br /> Domestic/public DrivenGauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: MState 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 become subject to Workman's Compensation <br /> laws of California. " " <br /> I WILL CALL FOR A .GROUT •INSPECTI ON PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 2.36 9 <br /> (DRAW PLOT PLN ON REVERS SIDE <br /> FOR J)EPARTMENT USE ONLY <br /> PHASE I /11 <br /> APPLICATION ACCEPTED ,.BY ni fl DATE 1; /7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECT" BY DATE INSPECTION BY DATEA1/^ <br /> s ._ <br />_EH 1426 Rev. "12-77 ] 'f 78 2M i <br />