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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ,S` <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/ <br /> j� This Permit Ex ices 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. <br /> EXACT STREET ADDRESS CITY/TOWN !'C<G'z <br /> Owner's Name /' Phone -5 5'- <br /> Address - -7 //ro7� City B,G <br /> Contractor' s Name r License#/g7�_ Phone 117dV <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATI01,1 TINSURA"10E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLM DEEPEN O RECONDITION DESTRUCTION C] <br /> WELL CHLORINATION Q ABANDONMENT 0 OTHER 0 L-► <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT [I 'I,*- <br /> NJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIME -. 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 's <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor •rc�. �� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑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 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED r 1 ' TITLE: DATE: �d <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMEN7 USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE/,5:;;'— <br /> EH <br /> ATE ,EH 1426 Rev_ 19-77 c 1/78 2M <br />