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SAN JOAQUIN Lf,%At;'Ka` JH UI5IRIUJ <br /> FFI'CE USE: 1601 E. Hazel t K*'Ave, , Stockton, CA 95205 Permit No. <br /> i Telephone: (209) 466-6781 - s 3 <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/ _,�7,,8' <br /> Th s Permit -Expires 'I Year From Date Issued <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 /> Loanuin County Ordinance No. - 1862 and the Rules and Regulations of the San�Joaquin Local Health <br /> GiStr'Ct. <br />, EXACT STREET ADDRESS a 53 CITY/TOWN <br /> Owner's NameI& I i� Phone <br /> 3 <br /> Address <br /> t C i ty� �.., <br />' Contractor' s Name � 10 <br /> License# � Phone <br /> IS CERTIFICATE OF WORKNIANJ'S COMPENSATIO1111 INSURANCE ON FILE WITH SJLHD? YES ;40 <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN ❑ RECONDITION Q DESTRUCTIONED t -. .�- <br /> o <br /> WELL CHLORINATION E1 WELL ABANDONMENT ❑ OTHER <br /> PUMP INSTALLAT-ION`E] PUMP REPAIR PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC <br /> TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER -L <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL s <br /> - .INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We11 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 F Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type af1Pump H.P. ' <br /> PUMP REPLACEMENT: State Work Done <br /> MP REPAIR: [State Work Done <br /> PU - <br /> DESTRU'C7ION OF_WEfL:` Well piamete Approximate Depthµ <br /> Describe Materia - and Procedure <br />[ hereby certify that I have prepared this application and that the work will be done in accordance' <br /> vith San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Local , <br /> lealth 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. " I f <br /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED TITLE: DATE: p <br /> ` " D ' W PLO PL N ON REVERSE SI E <br /> q <br />'HASE IFOR DEPAR MENT USE ONLY <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS : Z4&nDATE leir <br /> PHASE II GROUT: INSPECTIO - <br /> NSPECTION BY PHASE III .FINAL INSPECTION � <br /> DATE INSPECTION BY,/ DATE <br /> - 1426 . . Rev. 12-77 <br /> _ .__ <br />