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FFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRIX"r <br /> 16(,,E. Hazelton Ave. , Stockton, CA,,,,5205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /—.F- 7 <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 <br /> District. Rules and Rlgulaions� San Joaquin Local Health <br /> E C <br /> EXACT STREET ADDRESS � [" L// 3 3, CITY/TOWN ��� k�d.., <br /> Owner's Name Ve /dam ! <br /> Address Phone_1� <br /> S.c�w,� City , ,? S <br /> Contractor's Name— License Phone <br /> IS CERTIFICATE OF WORKMAN'S COMSPENSATION INSURANCE N FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELLLD DEEPEN RECONDITION Q DESTRUCTION <br /> WELL CHLORINATION a WELL ABANDONMENT L OTHER ( G <br /> PUMP INSTALLATION 0 PUMP REPAIR 0 PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK,O_�t SEWER LINES / PIT PRIVY <br /> SEWAGE DISPOSAL FIELDED 'F CESSP OL/SEEP�IGE PIT OTHER <br /> PROPERTY LINVb--PRIVATE DOMESTIC WELLS2DOM <br /> 4 PUBLIC ESTIC WELL — <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _Cable Tool Dia. of We 1 Excava <br /> _ tion) — Domestic/private Drilled Dia, of Well Casing // <br /> Domestic/public Driven Gauge of Casing f ' dT,a �y <br /> Irrigation Gravel Pack Depth of Grout Seal 9j--t` <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical µ ^ <br /> Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H <br /> PUMP REPLACEMENT: [IState 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 accordan< <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 CA FOR GRO T I SP TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> W PLT L N ON REVERS IDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY J DATE 1977 <br /> ADDITIONAL COMMENTS: —� <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTI <br /> INSPECTION BY_ � DATE INSPECTION BY �I,wl DATE S Q I )?Z <br /> EH 14 26 Rev. q/7R —���� - n— O ' ';— <br />