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SAN JOAQUIN LOCAL HEALTH UISIRICI <br /> FOR _OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. _If,3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3 J�7 <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Trip icate <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 Lj ;, � .fiz.; CITY/TOWNj1 � ,,, <br /> Owner's Name_• /� «wry Ld `, Phone 2149 <br /> Address 2 al 204'' I+ CityKQv �s"z � <br /> Contractor's Name License#` ;? _ Phonegy _ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSUR �•JCE ON FILE WITH SJLHD? YES ,� NO <br /> TYPE OF WORK (Check) : NEW WELL L( DEEPEN ❑ RECONDITION ® DESTRUCTION❑ ., <br /> WELL CHL"R NATION ❑ WELL ABANDONMENT ❑ OTHER <br /> PUMP INSTALLATION C7 PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD -----CESSPOOL/SE PAGE PIT OTHER — <br /> • PROPERTY LINVOPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 42 <br /> Domestic/private Drilled Dia. of Well Casing r+ ` <br /> Domestic/public Driven Gauge of Casing i <br /> Irrigation Gravel Pack Depth of Grout Seal- <br /> Cathodic <br /> ea Cathodic Protection V Rotary Type of Grout <br /> Disposal Other Other Information �M E� <br /> Geophysical Surface Seal Instal ed by. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 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 Workman's Compensation <br /> laws of California." <br /> I WILL CALI, FOR A GROUTASP, Tjo/' <br /> RIOR TO GROUTING AND A FINAL INSPECTION. ` <br /> SIGNED <br /> DATE: <br /> TITLE: � r <br /> pR W FLFT PLTN ON REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY --� , t. c` DATE <br /> ADDITIONAL COMM <br /> P A II GROUT INSPECTI N ASE III FINAL INSPECTION <br /> INSPECTION BY DATINSPECTION BDATE.14/7 otOV2 e^0° <br /> EH 1426 Rev. 12-77 (j7 f 7 <br />