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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USSP O 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.2 - /O Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 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 /> Joaquin County Ordinance No. 1862 and the .Rules and Regulations of the San Joaquin Local Health <br /> District. ��;; V f' �lj/r r `PX <br /> EXACT STREET ADDRESS 000KI Pnad 6-0 CITY/TOWN /5�`7` . <br /> Owner's Name S ,*, Phone 2)2 F3 <br /> 5 -- -- 9� - <br /> Address _ <br /> --/-�/U �., ������ -l�c.r� � - - --- City <br /> Contractor's Name ,# r �aer �'� /r, �=r� License#PF. ��6� Phone(i`6� l <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATION INSURAMCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL C& DEEPEN 0 RECONDITION d DESTRUCTION' <br /> WELL CHLORINATION a WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR[3 PUMP REPLACEMENT p. <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 -30--t-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 ice, calms . <br /> Cathodic Protection Rotary Type of Grout c . <br /> Disposal Other Other Information <br /> Geophysical _ _ Surface Seal Insta ed by: <br /> PUMP INSTALLATION � Co tract-6r <br /> Type of Pump H.P. <br /> 'l <br /> PUMP REPLACEMENT: ❑State Work Done a <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material 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 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. " <br /> I WILL C OR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE-A , J; DATE: 7,6> <br /> (DRAW PL T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY_ T _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION/' R PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 54:� DATE ;7-c5 <br /> SEH-_1.426 Rev. 12-77 (0 1/78 2M <br />