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061.1' "A" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 160' Hazelton Ave. , Stockton, CA 205 Permit No. 74 - 615 <br /> R Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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 4les and Regulations of the San Joaquin Local Health <br /> District. j <br /> EXACT STREET ADDRESS 3 Hca CITY/TOWNc <br /> Owner's Name Y Phone <br /> Address � � <br /> v �- G City—s_e ' <br /> Contractor's Nam License# ti?-, -7"-hone 44:7 _ 7 7� <br /> IS CERTIFICATE OF WORK'iAN'S CO"i N TIOPJ IPJSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ® DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION [�d PUMP REPAIR 0 PUMP REPLACEMENT ❑ � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT � OTHER 0 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL-- PUBLIC D_OMESTIC 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 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor �-4 1 '�^ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: (]State Work Done <br /> PUMP- : ( State Work Done <br /> DESTRUCTION OF WELL: Well Diameterapproximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc <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; ,f s _ .I TLE: DATE: C^ e r7 <br /> PLOT PL ON REVERSE SIDE <br /> FOR DEPARTMENT USF,,ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �Q.. DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> L----v <br /> Z . <br /> EH 14 26 Rev. 9/78 i Q grl <br />