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Ir, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4� <br /> EOR. OFFICE USE: 1601 E. Hazelton Ave. ,-Stockton, CA 95205 Permit No.z�L/ ;7 <br /> Telephone: (209) 466-6781 <br /> I, APPLICATION FOR WELL CONSTRUCTION. OR PUMP PERMIT Date Issued2 <br /> This Permit Ex .ires 1-Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a`pe'rmi�t to construct <br /> E Arid/or install the work herein described. ..This application is made in compliance with San <br /> ,'oaquin County Ordinance No. 1862 and the Rules ar'd Regulations of the San'-Joaquin Local . Health <br /> 'district: <br /> EXACT STREET ADDRESSCITY/TOWN Z) <br /> Own'er' s Name / .0 4 6- J Phone <br /> Address D a City .L cry Ile ca/ <br /> Contractor's Name License# Phone <br /> TS CERTIFICATE OF WORKMAN'S C0111PENSATIO'1 INSURAINCE ON I=ILE WITH SJLHD? YES NO' <br />'"T_YPE-OF"'WORK (Check)-: NEW WELLU DEEPEN EJ RECONDITION ❑ DESTRUCTION❑ - �,- <br /> WELL CHLORINATION Q WELL ABANDONMENTS OTHER { <br /> PUMP INSTALLATION CRr PUMP REPAIR❑ PUMP REPLACEMENT C) <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 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/ <br /> Type of Pump ! ,. , .,.__...—, _ H.P. IF 6 <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: O State Work Done a <br /> _DESTRUCTION OF WELL: Well Diameter . `�� Approximate Depth 60*0 d <br /> Describe Material and Procedure <br /> s _ 7 <br /> I hereby certify that I h ve 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 .such4manner as to become subject to Workman's Compensation <br /> laws of California." <br /> i WILL CALL. FOR A OUT INSPECTION- PRIOR�TO GROUTING AND A-FINAL INSPECTION. b <br /> SIGNEDiTITLE: 6? DATE: <br /> (DRAIWLOT PLAN ON REVERSE SIDE <br /> P11)L", <br /> R PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: s <br /> PHASE II GROUT INSPECTION a PHASE III FINAL INSPECTION <br /> INSPECTION BY 414 DATE _ INSPECTION BY DATE <br /> FFA 147Fi Rau 17_77 ' 7 /7S2 W <br />