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SAN JOAQUI1'4j'LUCAL HEALTH UISTRICT FEL6FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. i Telephone:' (209) 466-6781 F APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7J This Permi t' Ex i res :1 .Year From, Date Issued r Complete In Triplicate) S-7- 67 OL Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. EXACT STREET' ADDRESS _ `.. ' ` "� ITY/TOWN k Owner's Name Phone F Address _ City_-F��?�r-1« Contractor's Name L i c e n s e#,?,?S Phone F IS CERTIFICATE OF WORKMAN'S COMPENSATIOPJ IN RA1rJCE ON FILE WITH SJLHD? YES X _ NO TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION EJ ! -WELL CHLORINATION ❑ WELL ABANDONMENT 0 -OTHER❑ PUMP INSTALLATION EJ PUMP REPAIR❑ PUMPREPLACEMENTC �� DISTANCE TO NEAREST: SEPTIC TAN p/4 SEWER LINES SPIT PRIVY - - SEWAGE DISPOSAL FIELD a--- CESSPOOL/SEEPAGE PIT OTHER h PROPERTY LINEV PRIVATE DOMESTIC WELL-�50PUBLIC DOMESTIC WELL 4= INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Industrial �rCable Tool Dia. of Well Excavation Domestic/private Drilled Dia. of Well Casing Z2 Domestic/public Driven Gauge of Casing ` "Irrigation Gravel Pack Depth of Grout Seal � d Cathodic Protection Rotary Type of Grout { ,,Disposal Other Other Information - Geophysical Surface Seal Installed by: PUMP INSTALLATION: Contractor I Type of Pump H.P. PUMP REPLACEMENT: ❑State Work Done PUMP REPAIR: ❑State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance t with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Homeowner or licensed agent' s signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person -in such manner as to become subject to Workman's Compensation laws of California." I WILL C FORA ROUT P T RIOR TO GROUTING AND A FINAL INSPECTION. SIGNED �� d, TITLE: DATE: } D W FLY L N ON REVER SIDE FOR DEPARTMENT USE ONLY PHASE I APPLICATION ACCEPTED BY DATE ADDITIONAL COMMENTS : PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION INSPECTION BY DATE INSPECTION BY "-` DATE `.EH.-.1467_ Rev. 12-77 _ 1178 2M;