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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _F,2L FFiCE USE: 1601 E. Hazelton Ave., Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7 <br /> This - Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate _ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> dnd/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 /> 'district. 2 <br /> EXACT STREET ADDRESS J 5 S CITY/TOWN <br /> Owner' s Name V, Phone_�Z"�- 3 gS�f <br /> Address City <br /> Contractor' s Name j,� ._ Li cense# Phone <br /> YS CERTIFICATE OF WORKMAN'S COMIPENSATIO'1 INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTIONED <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER❑ v <br /> PUMP INSTALLATION W 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 WE_LLPUBLIC DOMESTIC WELL - <br /> INTENDED USE TYPE OF WELL Y 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 /> Cathodic Protection Rotary . 'Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor / <br /> Type of Pump - -:S*11f m.1-r-F &- 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 have prepared this application and that the work will be done in accordance <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: DATE: <br /> (DRAW PL T PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY e DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE/0-5-78 <br /> EH 1426 Rev. 12-77 t�/l3/��' '^ �' � �'"`� r',' `�` ' <br /> - - - - - _ - �-�- - 1/78 <br />