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r-----: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466 .6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT pate Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate , <br /> Application is- hereby made tolthe San Joaquin Local Health District for a . permit to .cons,truct <br /> and/or install- the work herein described. 'This -application is made in .compliance with. San <br /> . oaquin County Ordinance No.� 1862 and the Rules and Regulations .of the- San Joaquin Local Health <br /> ;strict. �/ -7� Q 0EXACT STREET ADDRESS CITY/TOWN 5(;1 18 Y1 - <br /> Owner's Name Q V :Xc ',Phone <br /> Address 14 -» City. <br /> Contractor' s Name %A4 IP <br /> License#,32&413�1 Phone%5.2C� <br /> ��— <br />'S CERTIFICATE OF WORKMAN'S 011PENSATION I11SURANCE ON FILE WITH SJLHD? YES NO <br /> TYPEaO.F---W.OR.K-(_Check)_::;,,NEW-.WELL-0- DEEPEN-[3--; ,RE.C.ONDI_T.ION_0--;_DESTRU.CTION.O-.--. <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION J8 PUMP REPAIR❑ PUMP REPLACEMENT [ ' <br /> DISTANCE TO NEAREST: SEPTIC ;TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL 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 <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing s; _ <br />---R---Irrigation i Gravel Pack Depth of Grout- Seal <br /> Cathodic Protection RRotary , Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor , ,eI <br /> Type ofjPump <br /> PUMP REPLACEMENT:. [] State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: _-,Well Diameter Approximate_De t.h ' <br /> - V -_ .,ti - p <br /> Describe Material and Proce ure <br /> I hereby certify that I have prepared 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. 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,ato Workman's Compensation <br /> laws of California, " <br /> I WILL C"FOROUT INSPECTION PRIOR TO GROUTING AND A FINAL41NSPECTION. <br /> SIGNED DATE: 4, 1 <br /> R W PLOT PLAF ON REVERSE S <br /> F R DEPARTMENT USE ONLY <br />'HASE I is <br /> TPPLICATION ACCEPTED BY DATE <br /> kDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION 11H ASA F AL I PECTION <br /> NSPECTION BY DATE INSPECTION BY TE �z f <br /> H 1426 Rev. 12-77 1 ,-,Q <br /> C+ <br />