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SAN JOAQUIN LOCAL; HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. �S <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex i res 1 Year From Date Issued /"- crd.G � <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 /> dcaqui n County Ordinance 1,o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br />'EXACT STREET ADDRESS ����0 CITY/TOWN <br /> Owner's Name (�jQpJ,�, _ Phone 2q -26 50 <br /> Address Q, City <br /> Contractor' s Name Qty License# Phone <br /> IS CERTIFICATE OF WORKMAN`S COMPENSATIO"1 INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION [] DESTRUCTION[2 <br /> WELL CHLORINATION WELL ABANDONMENT Q OTHER 0 w <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY f3` <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Cn <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor 4-M;A - <br /> Type of Pump H.P._ 'Q <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: C--]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 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 4 .CALL FOR A GROUT INSPECTION P IOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 0 TITLE: © DATE4:�� <br /> (DRAW PLOT PLAN ON REVERSE SIDE C <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 14 Z DATE Z� <br /> ADDITIONAL COMMENTS.: <br /> PHASE Ii GROUT INSPECTION PHASE I I INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION DATE <br /> EH 1426 Rev. 12-77 l' 8 2M <br />