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CD SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE:' 1601 E. Hazelton Ave.-, Stockton, CA 95205 Permit No. - y <br /> Telephone: (209). 466-6781 Date Issued t� 7? <br /> h APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (Complete In Trip 1 i cote} x� <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 3 l/- At feftSf. 0 ,1..fl CITY/TOWN <br /> Owner's Name h �'+ fPhone <br /> Address- 1 7 _City <br /> Contractor's Name / Lic;ensef&a Zy Phone <br /> IS CERTIFICATE OF WORKMAN'S C041SATION INSURANCE ON FILE WITH SJLHD? YES 0 <br /> TYPE OF WORK (Check) : NEW WELL C1 DEEPEN C! - RECONDITION DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT ® OTHER 0 - <br /> PUMP INSTALLATION M PUMP REPAIR PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE. DISPOSAL FIELD CESbLjSEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF-W-ELL CONSTRUCTION SPECIFICATIONS. co <br /> _ Industrial Cable Tool Dia. of 4ell Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 2C—Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of ,Grout <br /> Disposal Other Other Information <br /> - Geophysical A, � Surface Seal- Insta ed b <br /> PUMP INSTALLATION_: Contractor <br /> Type of Pump -� .�- H.P. <br /> PUMP REPLACEMENT: CIState Work Done a <br /> r PUMP REPAIR: OState Work Done <br /> DESTRUCTION OF WELL: Well Diameter ` / t Approximate Depth <br /> Describe Matefi_a7 an Proce ure, rt <br /> i A j <br /> I hereby .certify that I havelprepared this application and that the work will be done ,in- accordanc( <br /> with San-Joaquin County Ordinances , State Laws , and Rules and Regulations of the San.,Joaquin Local <br /> Health District. Horse 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 CALL FOR A GROUTE T IOR TO GROUTING,.-AND A FINAL INSPECTION. <br /> SIGNS TITLE: DATE: 41 / <br /> MD PL N ON REVERSE SIDE) <br /> FOR EPA TMENT USE ONLY <br /> .PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE IJ GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE _ , INSPECTION B DATE <br /> A 9/ <br /> FH l4 26 Rev. 78 <br /> s_, r g.. g . _2M <br />