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SAN JUAQU1N LUCAL NLAL.I,H 'U15EK1U1 <br />; FOR-OFF-IC-E USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 2 q-S2 o <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP. PERMIT Date Issued 3-2 g <br /> Thi s Permit Ex p i res 1' Year From Date- Issued <br /> ,. Complete In Triplicate <br /> AQplication 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 incompliance with San <br /> "oaquin County Ordinance No. 1862 and the 'Rules and -Regulations of the San Joaquin Local Health <br /> District, <br /> EXACT STREET AD SS 9 CITY/TOWN <br /> Owner's Name <br /> . Phone <br /> Address_ - ,�¢� . : City t <br /> Contractor'-s Name License# Phone <br /> 'S CERTIFICATE OF WORKi1AN'S C0'1PENSATiO'i INSURANCE ON FILE WITH SJLHD? YESNO _ - 1 <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ W <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 ~ <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT °4 <br /> D <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT ,,PRIVY � <br /> * j SEWAGE DISPOSAL FIELD CESSPOOL/SLEPAGE 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 of1Graut Seal <br /> Cathodic Protection Rotary . Type of Grout <br /> Disposal Other Other Info"rmation 1f. <br /> Ge( <br /> physics-1�- Surface Seal Ins ta$l_�ed_-b ! +. <br /> PUMP INSTALLATION: -&ntractor R ` it <br /> sr <br /> Type.jof Pump H.P. ; �_/ <br /> PUMP .REPLACEMENT- StateUork Done <br /> PUMP REPAi'R: p--° ETS"tate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance` <br /> with San Joaquin ,lCounty Ordinances , State Laws , and Rules and Regulations of the San` Joaquin Local <br /> Health District. Home owner or licensed agent' s signature cert ffles the following: <br /> "I certify, that in the performance of the work for which th"is 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 CALLF GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 44 4 TITLE: DATE z_ —XI <br /> (DRAW PLOT PL N ON REVERSE SIDE <br /> PHASE i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DAT,Ey <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE <br /> EH. 1426 Rev. :1277 1/78 2M <br />