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SAN JOAQUIN LOCAL HEALTH DI51RIC.i <br /> FICE USE: 1601 E. Hazelton__: "ve. , Stockton, CA 95205 Perini <br /> Telephone:: t No. _/tea <br /> P (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 9 fig' <br /> This Permit Expires I. 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 here0 <br /> in described• This application is made Jn 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 ADDRESSejf <br /> Z I CITY/TOWN <br /> Owner's .Name <br /> Address s ' Phone_ � y� <br /> Contractor's Name ` <br /> G i tf <br /> License / Phone <br /> IS CERTIFICATE OF 1J0�;KMAN'S C6MPENSATIO"! I�;SURAF"!CE ON FILE WITI1 SJLHD? YEg <br /> �a <br /> TYPE OF WORK (Check) : NEW WELL[] DEEPEN 04 RECONDITION ❑ - DESTRUCTION <br /> WELL CHLORINATION Cl WELL ABANDONMENT 0 OTHER 0 p <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT E] <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES�� PIT PRIVY SEWAGE --- <br /> DISP S L� IELD� CESSPOOL/SEEPAGE PIT , OTHER <br /> PROPERTY LIN 614PRIVATE DOMESTIC WELLS. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cabi e Tool Di a. ' of 'Wel 1 Excavati ons �� 641 <br /> 'Domestic/private Drilled <br /> Domestic/public Driven - - . Dia. of Well"kCasing « <br /> Irrigation "- Gauge of Casing- <br />- --� - Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection - Rotary T <br /> Disposal - Other ype of Grout <br /> Geophysical Otherslnformatlon <br /> i Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump H:P, . <br /> PUMP REPLACEMENT: Q State Work Done <br />'UMP REPAIR: QState Work Done . a <br />)ESTRUCTION OF WELL: Well Diameter <br /> Describe Materia an Proce ure Approximate Depth <br /> t <br /> hereby certify that I have prepared this application and ,that the work will be done in accorda m <br /> rith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> lealth 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 <br /> laws of California. subject to Workman 's Compensation <br /> WILL CALL FOR A GROUT INSP CTI PR 0 TO GROUTING .AND 'A FINAL INSPECTION. <br /> IGNED _ TITLE: DATE: <br /> PLOT PL N ON REVERS Si E <br />-EASE I FOR DEPARTMENT US ONLY <br />'PLICATION ACCEPTED BY z <br />)DITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTIONa <br /> ISPECTION BY PHA II INSPECTION <br /> DATE e/ > INSPECTION BY DATE Z <br /> 1426 - Rav_ ,12-77 <br />