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SAN JOAQUIN LOCAL HEALI-H D1STRiC-f <br /> ffFCE�II'S ': 1601 E. Hazelton Ave:1, Stockton, CA 95205 Permit No. L- <br /> Telephone: (209) 466-67.81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued S--6.7,f <br /> Thais Permit Expires I Year From Date :Issued <br /> Complete In Triplicate <br />' Application is hereby made to the San Joaquin Local - Health Distri-ct for.. a permit to construct <br /> and/or install the work hereii described. - This. application is made in compliance with San <br /> ,oaquin County Ordinance ado. 11862, and the Rules -and Regulations- of'. the San Joaquin Local_ Health <br /> District. <br /> EXACT STREET ADDRESS . <br /> CITY/TOWN,531'a,kr71 <br /> � _ <br /> Owner's Name {{ Phone 6 S <br /> Address �, <br /> City �.. <br /> Contractor' s Name <br /> n ,,,,� License#29 /$ Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"l—ItiSURA"iC ON FILE WITH SJLHD? YES e--- NO <br /> TYPE OF WORK (Check) : NEW WELL 0 /DEEPEN O' RECONDITION 2E�— DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION C1 PUMP REPAIR❑ J'- , PU_,MP REPLACEMENT � <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY -Is� <br /> SEWAGE DISPOSAL% FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE- ...PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL g . <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 I Rotary Type .of Grout <br /> f <br />� . Disposal Other Other Information <br /> T Geophysical, ., Surface Seal Instilled—by. <br /> PUMP INSTALLATION: ' Contractar <br /> Type- of PumpI <br /> � H. . <br /> PUMP REPLACEMENT: -4 <br /> []State Work Done <br /> PUMP REPAIR: []State Work Done <br /> DESTRUCTION OF WELL: Well Diameter, Approximate Depth <br /> Describe Materia and' 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 o'r .licensed-,agent's signature certifies the following: <br /> I certify that in the performance of the .work for,which- this permit . is is.sued,_,I_shall_ <br /> not employ any person in such manner as to 'b'ecom'e s <br /> ecome subject to Workman ' Compensation i <br /> laws of California. " x <br /> I WILL CALL FOR A GROUT_I.NSPECTION PRIOR TO.GROUTING ANDIA'FINAL INSPECTION. <br /> SIGNED TITLE: DATE:-:?/ <br /> DRAW PLOT PLTN ON REVERSE SIDE <br /> FOR <br /> DEPARTPHASE I MENT USE ONLY <br /> APPLICATION ACCEPTED BY � DATES " <br /> ADDITIONAL COMMENTS: j - <br /> PHASE II GROUT INSPECTION PHASE JIINAL INSPECTION <br />:NSPECTION BY DATE INSPECTION BYDATE - - q`�� <br />:H 1426 Rev. 12-77 <br />