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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: _�2Q9,) Y46676781 <br /> AAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date wlssu,e l-7 �O- 0 <br /> Theis Permi I t _Exp ires 1 Year -Fr.om Date Issued <br /> L Complete In Triplicate <br /> Application is hereby made t: 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 J 1862 and the- s and Regulations of the San Joaquin_ Local Health <br /> District. <br /> EXACT STREET ADDRESS i CITY/TOWN <br />' Owner' s Name Phone <br /> Address City. <br /> Contractor' s Name 'XF License# T/3. Phone �31 <br /> \ i �r-- .. <br /> IS CERTIFICATE OF WORKMAN'S CnmPENSAT 0'N INSURANCE ON FILE WITH SJLHD? YES NO <br /> j TYPE OF WORK (Check) : NEW WELL DEEPEh_0—�RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION Q WELL\ABANDONMENT 0 OTHER 0 <br /> -�- TPUMP-I-NS-TAL-LATION (] --PUMP REPAIR-0 -'PUMP-REPLACEMENT <br />{ DISTANCE TO NEAREST: --SEPTIC-TANK--—S-EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ,PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL, 0 <br />` INTENDED USE �_ TYPE OF, WELL Z' CONSTRUCTION SPECIFIC TI RS a-1 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _Domestic/private D H1 11 ed Dia. of Well Casing Is X40C <br /> Domestic/public Driven' Gauge of Casing <br /> Irrigation Gravel Pac� Depth of Grout Seal <br /> Cathodic Protection -=Rp.tary ` r Type of Grout <br />! Disposal Other _ t. Other Information <br /> Geophysical �'t Surface Seal Installed b : r' <br /> a <br /> PUMP INSTALLATION: Contractor ' F r <br /> r Type of'Pump H. �.- <br /> PUMP REPLACEMENT: ( State' Work Done ' <br /> PUMP REPAIR: []Staite Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ti J. <br /> - <br /> I hereby certify that I have ,;prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances , Stat-e-Laiws, 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 C `fornia. " <br /> I �. <br /> OI WILL CALL A GROUT--INSP ION PRIOR TO-GROUTINGA""�P-F-1, <br /> AL IN PE N. <br /> SIGNED ,• TITLE: ` DATE: �a <br /> l c V DR W-P,L T PLAN ON REVER SIDE <br /> `�► <br /> PHASE I FOR DEPARTMENT U QNLY <br /> --�. <br /> APPLICATION ACCEPTED BY _ ,C,,� DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II ROUT INSPECTION l .PHASE III F N L INSPECTION <br /> INSPECTION BY DATE_ Z INSPECTION BY DAT <br /> EH 1426 ' Rev." 12-77 1 /78 2M <br />