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SAN JOAQUIN LOCAL .H£ALTH DISTRICT <br />�MEFFI=CE USE: 1601 E. Hazelton' Ave: ,:'Stockton, CA 95205 Permit No.7g�,)_ <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit •E' fres I Year From bate Issued <br /> Complete In Triplicate i <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 incompliance with San <br />' .Aanuin County Ordinance "+o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT. STREET ADDRESS "� - CITY/TOWN f <br /> Owner' s Name Phone <br /> Address t CitY <br /> Contractor' s Name L-i-cense Phone <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATIO"i INSURANCE ON `FILE WITH SJLHD. YES 140 <br />; TYPE OF WORK (Check) : NEW WEL LEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELD CHL-OR�INATION ❑ WELL ABANDONMENT E3 OTHER ❑ �! <br /> Plump, El ElPUMP'�REPA-IR,❑ PUMP REPLACEMENT EJ � <br /> DISTANCE TO NEAREST: _ EPT.IC4TAN-K• WWER LINES PITFiPRIVY <br /> (SEWAGE DISELD CESSPOOL/SEEPAGE PIT OTHER .� <br /> 3N. . 1 ;,PROPERTY LINE -, PRIVATE DOMESTIC WELL "` PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPEOF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br />�3E_ K:Domestic/private Drilled Dia. of Well Casing vV <br /> Domestic/public Driven Gauge of Casing V <br /> i Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : .- <br />( PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. - - <br />' PUMP REPLACEMENT: Q State Work Done f <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCT.�'ON OF WELL: Wel l4Diameter ARproximate Depth <br /> , Describe Material and Procedure <br /> , <br /> I her ertify that I have prepared this application and that the work will be done in accordance <br />=whoa uin Count Ordinances State Laws and Rules and Regulations of the San Joaquin Local <br /> q Y 9 <br /> Ho'a,lth 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 PRJ R TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE: DATE; evcl-r- _51hy <br /> D PLOT PLAN ON *,EVERSE SIDE) pc <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ; '? <br /> APPLICATION ACCEPTED BY DATE /- Z " 21 <br /> 'ADDITIONAL COMMENTS : i <br /> k PHASE II GIR&JT INSPECTFON . - PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE _1-1P ` �l g INSPECTION BY DATE -Z - 6- 77 <br /> ru 1e11G oma,. 11)_77 °~ 1J 78 2M <br />