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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F�LEI�55CEUSE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7S'-1s-1 <br /> Telephone: - (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/D 2 5- 2ff <br /> This Permit Expires 1 Year From Date Issued <br /> i 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 <br /> District, <br /> EXACT STREET ADDRESS CITY/TOWi � <br /> Owner's Name Phone ' � ► <br /> Address " �^ <br /> City <br /> Contractor's Name s Li censer *.k o Phone , <br /> .� <br /> IS CERTIFICATE OF WORKMAN'S CO`iPENSATIO"! IiISURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Z DEEPEN 0 RECONDITION ❑ DESTRUCTION[D. <br /> WELL CHL15RINATION Q WELL ABANDONMENT a OTHER b <br /> PUMP INSTALLATION ; I PUMP REPAIR C1 PUMP REPLACEMENT EI <br /> DISTANCE TO NEAREST: SEPTIC TANK �'�' EWER LINES PIT PRIVY ` <br /> SEWAGE DISP SAO,rLD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PR'IVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing -�' `[ <br /> Irrigation Gravel Pack Depth of Grout Seal ­ <br /> 00 <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> -- Surface Seal Instal ed b : <br /> PUMP INSTALLATION: Contractor fix, <br /> Type of Pump H. <br /> PUMP REPLACEMENT: FJ State,.Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter- `'€ a Approx-i-mate Depth <br /> Qesc:ribe Mat;rial an2 Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <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 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED .- TITLE: m DATE: 7 <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f. <br /> APPLICATION ACCEPTED B :�s DATE <br /> ',ADDITIONAL COMMENTS: - �� <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSP€CTION <br /> ! INSPECTION .BY.= DATE INSPECTION BY DATE <br /> .FH i dPA t2n4d ' 19-77 1 i-70 01KA <br />