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SAN JOAQUIN LOCAL HEALTH DISIKIUI <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. �_ 7 <br /> Telephone: (209) 466-6781 <br /> zf <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued J <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 of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS > . , CITY/TOWN Fmweao <br /> Owner's Name --7 L Phone 6 r <br /> Address 0. City F <br /> Contractor;' s Name r i cense# dZ Phone -S� <br /> ' TS CERTIFICATE OF WORKMAN'S COliPENSATIO,d INSURANCE ON FILE WITH SJLHD? YES fI� NO <br /> TYPE OF WORK (Check) : NEW WELL C] DEEPEN RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION C7 PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK_Lgo!_ SEWER LIMES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMEST,C WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4LCable Tool Dia. of Well Excavation -Aa 77 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing_ <br /> Irrigation Gravel Pack Depth of Grout Sea <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 t1, H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑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 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 WDrkman's Compensation <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AN A FINAL INSPECTION. <br /> SIGNED TITLE: OUNE12, DATE: <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR D£P RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYh� Z ec, DATE ?/7/1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASF1 I AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE L- 2 fZ <br /> t EH 1426 Rev. 12-77 1/78 2M.� <br />