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r FOS `vlV)k SAN JOAQUIN LOCAL HLALTH UIS I RRL:E <br /> FFICE 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 Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Aoplication 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 /> ,'oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name Phoner� .-37,29' <br /> Address City <br /> Contractor' s Name w, „/ License#,,2Phohe19? _,,2.2d <br /> L'S CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES 'l0 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ® DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIRfO PUMP REPLACEMENT ❑ _1�1\ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 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 <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 <br /> Type of Pump H. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: - [ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> : <br /> Describe Material and Procedure App oximate Depth <br /> I hereby certify that I have prepared this application and that the work will be done in accordana <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 F A GROUT IN ECT ON PRIOR TO GROUTING AND A FIUAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DR W PLOT PL N ON REVERSE SIDE <br /> FOR D PAR MENT USE . NLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE16- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I tINAL kNSPECTION <br /> INSPECTION BY DATE A�, INSPECTION BYATEJ'11917r <br /> EH 1426 Rev. 12-77 - 1 Q r)M <br />