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-- SAN JOAQUIN LOCAL HEALTH DISTRICT '�- <br />--FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit'IVo. 2 y_.18' <br /> Telephone: .(209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR UMP PERMIT Date Issued _3-7 <br /> This Permit Expires 1' Year Fr4m D e Issued <br /> Complete In Tripli ate <br /> Application .is hereby made to the San Joaquin Local He lth Dis. c r per t t cotruct <br /> p <br /> and/or install the work herein described. This applic tion is a in "0i <br /> e with San <br /> Joacauin County Ordinance No. 1862 an the Rules and Reg atien of the in Local Health <br /> District. l qo;3 S L a)e,6 . ;elec- <br />£xACT STREET ADDRESS - of a Y0, I?l — CITY/TOWN <br /> Owner' s Name Phone ` <br /> Address y City <br /> Contractor's Name . License# 29 /3 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLIX DEEPEN ❑ RECONDITION [J DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 �. <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK_pp f SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDS CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 09 <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 __y Gravel Pack Depth of Grout Seal -- <br /> Cathodic Protection Z_Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H• . <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 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 Wp man''s Compensation <br /> laws of California." �� 6 <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FI AL I SECTION. <br /> SIGNED TITLE: DATE:_ %?-IY- 7$ <br /> tDVAW PLT PLON REVS S ID <br /> FOR DEPARfMT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 4TE 4,6�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III F L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 Rev. 12-77 �1/78 2M <br />