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h SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Zo FICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (2091) .466-:6781 Date Issued _3-7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <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 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 0 <br /> Di s t r i ct. 3 s s. 7-A- ?�l �'-°- <br /> EXACT STREET ADDRESS Q 'w oar7`` 61 :'� CITY/TOWN`-, <br /> , <br /> Phone <br /> Owner's Name <br /> City: <br /> Address //. 00 � �' �� �- . - - ,- - <br /> r Contractor's Name License#�1�7�-� one <br /> IS CERTIFICATE -0 F WORKMAN'S AMASATION INSURA^!CE ON FILE WITH SJLHD? YES 0 <br /> TYPE OF WORKCheck) : NEW WELL U DEEPEN C] RECONDITION [3 DESTRUCTION( <br /> WORK ( <br /> WELL CHLORINATION E3 WELL ABANDONMENT 0 OTHER 0 j - <br /> + PUMP INSTALLATION 0 PUMP REPAIR' o PUMP REPLACEMENT El <br /> DISTANCE- TO NEAREST: SEPTIC TANK SEWER LINES , PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSM QSEEPAGE PIT OTHER f� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> f. <br /> Industria Cable Tool Dia. of Well Excavation <br /> _ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> k Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> f PUMP INSTALLATION: Contractor <br /> Type of Pump �_.. <br /> PUMP REPLACEMENT: C1 State .Work Done E ` <br /> PUMP REPAIR: 51State,_Wprk Done <br /> k DESTRUCTION OF WELL: Well 'Diameter Approximate Depth <br /> Describe Materi—al ana Procc ure <br /> I I- hereby certify that I have prepared this application and that the work will be done in accordan <br /> with San Joaquin County Ordinances , State Laws , and Rules and. Regulations of the San-Joaquin Loca <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 CA L FOR A GROUT INSPECC-TIN RTOR�'T© GROUTING AND A FINAL INSPECTION. <br /> SIGNS ' ITLE: _ DATE: 1 6 <br /> qap��/� L T ON REVERSE: SIDE <br /> OR D RTMEN USE ONLY <br /> PHASE I <br /> , APPLICATION ACCEPTED B. P _� 4- � z - I) � -n DATE <br /> ' ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASI III FINAL INSPECTION <br /> +INSPECTION BY DATE INSPECTION BY' DATE 7 <br /> ,EH 14 26 Rev. 917 :_ 4e. . 9' 78""- .2M' <br />