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SAN JOAQUIN •LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. --KJjI-K <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued `7- 1��`7• <br /> This Permit -Expires 1 Year From Date Issued <br /> Compl ete�-l.n. 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 /> ,'oaqui n County Ordinance 1o� 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District, <br /> EXACT STREET ::ADDRESS d �Q CITY/TOWN <br /> Owner's Name "F' Phone _ ( T <br /> Address <br /> C i ty <br /> Contractor' s Name , Phone / :?v <br /> IS CERTIFICATE OF WORKMAN'S''COMPENSATIO�1 INSUR;4NCE ON FILE WITH SJLHD? YES Lr NO <br /> ,, TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION[j <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> , DISTANCE TO NEAREST: SEPTIC TANKOW_irSEWER LINES PIT PRIVY C <br /> SEWAGE DISP SO AL FIELD,��CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation rf <br /> �mestic/private Drilled Dia. of Well Casing8,7 <br /> Domestic/public Driven - Gauge of Casing <br /> gation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ___A,=Retary Type of Grout <br /> Disposal Other ' Other Information <br /> Geophysical Surface Seal Installed 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 ,ha.ye-T�prepa.red�this application and that the work will be done in accordant <br /> with San Joaquin County Ordrn-ances`-; State -Laws, ,and Rul-es4and Regulations of the San Joaquin Local <br /> Health District. Home owneri'or licdnsed agent' sstgn,ature certifies the following: <br /> "I certify that in the performance of the wo.r_k for _whjch this permit is issued, I shall . <br /> not employ any person in' such manner as to become, subjpct to Workman's Compensation ` <br /> laws of California. " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING ANDiA FMO INSPECTION. <br /> SIGNED _ TITLE: t �` DATE: '711d-7 <br /> (DRAW PLOT PUN ON REV SE SIDE <br /> j,,FORS, DEPARTMENT USE ONLY <br /> I PHASE I ' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: fii . <br /> PHASE II GROUT INSPECTION '� .br PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE I INSPECTION B.Y.-.. DATE_ <br /> (E-H 142A Rav ` `1 9-'77 - � �• � a : � � ��� 1 /7A 7M <br />