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SAN JOAQUIRi LOCAL HEALTH DISTRICT ' <br /> FOR OFFICE USE: 1601 E. Hazelton Ave,. , . Stockton, CA 95205 Permit No. V'` -70-3 <br /> Telep�o- ne: (209}. 466-6781 <br /> APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT Date Issuedb- +7-? <br /> Thi-s Permit Expires 1 Year .From. Date Issued <br /> Complete In Triplicate <br /> Application is hereby made tolthe San Joaquin Local Health- District for a permit .to. construct <br /> and/or install the work herein described. This application is made ire compliance with San <br /> ,'oaou-in County Ordinance No. 1862 and the, Rules and Regulations of .the San Joaquin .Local Health <br /> District. dfptf �r <br /> EXACT STREET ADDRESS CITY/TOWN 4 <br /> Owner' s Name ,DPhone , Cog_ ___ <br />..Address , �" t City <br /> Contractor's NameLicense#33 / Phonef <br /> ,. <br /> 00, <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'! INSURANCE ON FILE WITH SJLHD? YES NO <br />€ TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PLUMP REPLACEMENT ❑ <br /> DISTANCE TO"N'EARES�tT-:---SEPTI-C--T-ANK—�S,EWER-LINES - - -.--P:IE PR-1=VY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE .PIIT OTHER g� <br /> PROPERTY LIN -?. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE a TYPE OF WELL CONSTRATION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public ' Driven Gauge of Casing i <br /> Irrigations Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout J <br /> Disposali Other Other Information <br /> Geophysic'a� Surface Seal Ins'',talled by: <br /> PUMP INSTALLAT100 Contractor <br /> -- Type of Pump H• . <br /> PUMP REPLACEMENT: c]StaIte Work Done <br /> PUMP REPAIR.- ❑State Work Done <br />( DESTRUCTION OF WELL: Well Diameter Approximate Depth <br />` Describe Material and Procedure <br /> Vii' <br />, I hereby certify that I have prep ra ed this application and that the work will. be done in accordance <br /> + with San Joaquin County ordinances, State Laws , and Rules and Regulatio s 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." I <br /> J WILL CALL FOR A INSPEC ION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPA T USE ONLY <br /> PHASE 'I DAT ]'rr <br /> APPLICATION. ACCEPTED BY00, <br /> ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINA SPECTION <br /> INSPECTION BY DATE INSPECTION BY DATERI-12hq <br /> IEH 1426' Rev- 12=77 1/78 2M'` <br />