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- 5AN JUAQU1N LW AL HtALIH U1J1K1U1 <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 [Date <br /> it No.7ff—��y <br /> GJ Telephone: (209) 466-6781 <br /> APPLICATION FO�WEL•L CONSTRUCTION OR PUMP PERMIT Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <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, f, the San Jo. quin Lo al Health <br /> District. `'"'' S. <br /> EXACT STREET ADDRESS , CITY/TOWNSs <a K <br /> Owner's Nance 0&1 G Phone <br /> Address City c.416 <br /> Contractor's Name Licensees /Z!�_ Phone <br /> 'S CERTIFICATE OF WORKMAN'S COI,',P£NSATIO�i I"dSLlR }•10E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLM DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION D WELL ABANDONMENT p OTHER rJ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANVi SEWER LINESI �4 PIT PRIVY <br /> SEWAGE DISPOSAL.FI£LD pjtf CESSPOOL/SEEPAGE PIT.r.--- *. OTHER <br /> PROPERTY LINVd PRIV Tl� F DOMESTIC WELL�L 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 ,e,a ' <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.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: Q State Work Done <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 accordancd <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 FOR A/)GRUg WXCTION PRIOR TO GROUTING AND A FINAL INSPECTION. � l <br /> S I G N E TITLE:; DATE: <br /> (DRAW PLOT PLAN ON REVER SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE '7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II;I FINA INSPECTION <br /> INSPECTION BY DATE INSPECTION BY// DATE <br /> EH 1426 Rev. 12-77 /�� 5 oak - _ . 1/78 <br /> ,'. <br />