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SAN JOAQUIN, LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 1 y`7 a 5 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -,:217-92 <br /> This Permit Expires I Year From Date Issued <br /> .Complete. In Trip irate <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 C` <br /> District. Ak- <br /> - !� <br /> r <br /> EXACT STREET ADDRESS 1103 G{� Pd CITY/TOWN <br /> Owner's Name Phone <br /> Address C/ City <br /> Contractor's Name Licensee/gy / Phone :,=JIFyc <br /> - � �_. <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"1 INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT 0 OTHER <br /> PUMP INSTALLATION_. PUMP REPAIR 0 PUMP'REPLACEMENT Q <br /> DISTANCE ,TO NEAREST: SEPT,I.C',TANK SEWER LINES PIT PRIVY <br /> SEWAGE'DISPOSAL FIELD CESSPOOL/SEEPAGE PITT OTHER <br /> • PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation r <br /> _Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing I <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geop�ysjical Surface Seal Installed by: <br /> PUMP INSTALLATtION: Contractor ; <br /> t- Type of Pump H.P. <br /> PUMP REPEACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4 y <br /> I hereby certify that I h va e4prepared this application and that the work+ wi11 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 FO GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:&-- �P_--z <br /> DR W PLOT PLTN ON REVERSE SIDE <br /> FOR DEP RT <br /> PHASE I USE ONLY <br /> APPLICATION ACCEPTED BY Q DATE Z S` <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PRASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> EH 1426 Rev. 12-77 1/78 2M <br />