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4 <br />�- a' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _ FOR OFFICE USE: 1601 E. Hazelton -Ave. , ..Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This, Permit Expires I Year From Date Issued <br /> Complete In Triplicate <br /> r <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 /> �oaqui'n County Ordinance No. 11862 and the Ru es and Regula ions of, the .,San Joaquin' Local ,Health <br /> S.istrict. C --�h} i <br /> F Si <br /> EXACT STREET ADDRESS !1(O ;� �/ CITY/TOWN Cerci , <br /> Owner's Mame } Phone <br /> Address City dl�—s4 .f?4 <br /> Contractor' s Name ' � �_ SLicense#Q730d0 Phone ,2 o-7 <br /> " 'S'CF-RTTPICATt OF WORKMAN'S CD°I,',PENSATIO"! I"JSURANCE ON-FILE -WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION C3 WELL ABANDONMENT p OTHER ❑ <br /> PUMP INSTALLATION 0 PUMP REPAIR 06 PUMP -REPLACEMENT CI � <br /> i <br /> DISTANCE TO NEAREST: . SEPTICITANK SEWER LINES PIT PRIVY. 0� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE :. .:PRIVATE DOMESTIC ,WE-LL -=.._- PUBLIC DOMESTIC WELL -- <br /> INTENDED <br /> ELL INTENDED USE TYPE OF WELL A CONSTRUCTION SPECIFICATIONS ; <br /> Industrial Cable Tool Dia. of Well Excavation 1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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:16 ';. Cantractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done _ <br /> PUMP REPAIR: [ZState Work Dong -A? b��'_ <br /> ��^p�,� i._... _ <br /> �--- - - - <br /> DESTRUCTION-.OF WELL: x Wel-1 Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify Tt atT 'I­-'Iave prepared this application and that the work will be done in accordancE <br /> with San Joaquin` Count3 Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health'Di'strict: 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 Compensat-ian" <br /> laws of California. " <br /> I WILL CALL FOR A4ROUT INSPEC N P IOR TO GROUTING ANDA KI_UL INSPECTION. <br /> SIGNED f TITLE.: - DATE:f-X";70@ <br /> -(DRAW PLOT PL N ON REVERE IDE <br /> , x <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED: BY,.,, DATE__;LI-717k <br /> ADDITIONAL COMMENTS; ..:I <br /> PHASE . II GROUT INSPECTION PHASE II FINAL JNSPECTION <br /> INSPECTION BY DATE INSPECTION BY, HATE <br /> EH 1426 Rpv 12-77 7A 7M <br />