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SAN JOAQUIN LOCAL HEAL-IH UISIKIGI <br /> OFFICE USE. 1601 E. Hazelton Ave. ,. Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued,;? <br /> This Permit .Ex i res 1 .Year -From Date Issued <br /> Complete In .Triplicate <br /> AQP lication 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 /> Loaquin County Ordinance No. 1862 and the Rules .and Regulations of the San Joaquin Local Health <br /> District. <br /> _ <br /> EXACT- STREET ADDRESS_..6LAJ S' CITY/TOWN <br /> 91&�, <br /> f <br /> Owner' s Name Phone3yS .5— <br /> Address P CJc / L�Sr - - City <br /> Contractor's Name License# , -3. Phone &32- �9_� 2- <br /> TS <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATION I11SURMICE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ® DESTRUCTION( —�- � - <br /> WELL CHL RINATION-, _ WELL ABANDONMENT ❑ OTHER <br /> PUMP INSTALLATION,% PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> 01 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ PIT PRIVY Cx <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF,,WELL �' .' .'. _CONSTRUCTION SPECIFICAT QNS <br /> Industrial,. ; Cable Tool. "=°--Dia, of Well Excavation <br /> Domestic/pri Vate _�. - - Drilled ,� ,,Dira. of Well Casing_ <br /> �c ^Domestic/public'. Driven Gauge-of Casing <br /> „ �.. <br /> Irrigation Gravel Pack Depth of Grout Seal _ j <br /> Cathdd•ic .Protection- Rotary . _'-Type of Grout <br /> Disposals - . .Other, Other Information <br /> Geophysical -� .f _ -,S.urface_SeaI Installed by:- <br /> PUMP INSTALLATION.: Contractor <br /> _ Type of Pump H.P. <br /> PUMP REPLACEMENT i . ❑ State Work Donee^ <br /> PUMP REPAIR: Q State Work Done <br /> i <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- Localy' <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 CAL GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGN TITLE: DATE: <br /> DR W PLT PLN ON REVERSE SIDQ-- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEp? <br /> ADDITIONAL COMMENTS: T 1 <br /> PHASE ILL UT INSPECTION PHASE III fINAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY DAT � <br />-F-H 142r% Rau 19-77 1 /7002M -A <br />