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SAN JOAQUIN LOCAL HEALTH DISTRICT <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 late Issued -/,-�- <br /> This Permit Ex fres l Year From Date Issued <br /> Complete In Tripl.icat� i <br /> Application is hereby made to the San Joaquin Local Health District fora ,permit to construct <br /> and/or install - the work herein described. This application is made in compliance with San <br /> Joaquin County OrdinanceiNo. 1.862 and the Rules and Regulations .of the San Joaquin Local Health <br /> District, <br /> EXACT"STREETSS SBC CITY/TOWf %al� <br /> w <br /> Owner's NameADDREL <"T W Phone (� <br /> Address 2 L- City ST Ta <br /> Contractor's Name t C WE!! e <br /> EA <br /> Li cense# Z Phonef'3 <br /> —7 <br /> IS CE:RTIFIC TE OF WORKt1A'J'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE & WORK (Check) : NEW WELL ga--- DEEPEN ❑ RECONDITION ❑ DESTRUCTION 3 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> . PUMP INSTALLATION ❑ , PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCEITOI'-NEAREST:" SEPTIC "TANK /Ad �� LLSEWER` LINES 'PTT"PRT1fY' �� <br /> SEWAGE DIS P AL FIELD CESSPOOL/SEEPAGE PIT OTH'.�R <br /> PROPERTY LI-NE--:,PRI-VATEfDOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TAPE OF WELL t—CONSTRUCTION SPECIFICATIONS <br /> atrial Cable Tool Dia. of�"We� T—Excavatii-On d� <br /> Domestic/private Drilled Dia. of Well Casing r ~ <br /> Domestic/public Driven Gauge of Casing �f <br /> Irrigation Eve.T,. Pack"' Depth of Grout Seal 61 <br /> Cathodic Protection Rotary: Type of Grout <br /> Di s�p.o.sal Other Other Information <br /> Geaph`ysical Surface Seal Instal ed b <br /> I <br /> PUMP INSTALLATION: Contractor ; <br /> i <br /> Type of Pump <br /> H.P. <br /> ' <br /> PUMP REPLACEMENT: [❑State Work--Done-- - �--- __' <br /> PUMP REPAIR: ❑State Work Done~ �� T <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia ; and Procedure 1 r <br /> I hereby certify that I have-prepared s application and that " he work will be done in accordance <br /> vith San Joaquin County Ordinances ; State Laws , andRules and Regulations of the San Joaquin. Local <br /> iealFth District. Home owner or licensed a ent's• signature cert I s. the,-fal1owin I <br /> I certify that in the, performance.of th—work—for which this permit is A ssued� I shall <br /> not empTby any personin_suc.h_manner as to become subject to Workman 's Compen 'ation <br /> -laws of California. " �— <br /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTI'NG _AND A FINAL INSPECTION. ' ` <br /> IGNED <br /> TITLE: LUN DATE �' L <br /> DR L T PL N ON REVERSE SIDE 4 <br /> I �. .. <br />'HASE I FOR DEPARTMENT USE ONLY -- -- f h <br /> APPLICATION ACCEPTED BY <br />,DDITIONAL COMMENTS: DATE <br /> PHASE I GROU;JNSPECTION "A <br /> PHAS III FINAL Bl INSPECTION <br /> NSPECTION '� DATE -S -IS, INSPECTION BY DOTE -S-1r <br /> H 1426 Rev. 12-77 <br />