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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ZZ-4.5�/ <br /> Telephone: : (209) 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> This Permit E ires 1 Year From Hate 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 /> Lloaouin County Ordinance No.. 1562 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS �S� CITY/TOWN <br /> Owner' s Name Ktz= MCC S tet; Phone r <br /> Address CIO . L Ci ty Pmch <br /> Contractor' s Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO X <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 N <br /> PUMP INSTALLATION R PUMP REPAIR❑ PUMP- REPLACEMENT ❑ oni <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 N' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �t <br /> Industrial Cable Tool Dia. of Well Excavation 3 <br /> omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 <br />'4 Type of Pump H.P. <br />' PUMP REPLACEMENT: []State Work Done <br />' PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well -Diameter Approximate Depth <br /> E Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc( <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> IHealth 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 /> kSIGNED ; v TITLE: DATE:-;124- <br /> ` DR W PLOT PLVN ON REVERSE SIDE <br /> f FOR-DEPARTMEt4T USE ONLY <br /> ' PHASE I I T DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHASE III FINAL INSPECTION <br /> s <br /> INSPECTION BY DATE INSPECTION BY �� DATE�'�� <br /> '- - - - -- 1/78 2M <br />