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SAN JUAQU1N .LUCAL, HEAL I H UIS I HIL I <br /> EOR OFFICE USE: 1601 E. Hazeltan Ave: ,: Stockton, CA 95205 Permit No. '7 g -7 o 6 <br /> Telephone: (209)• 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - 7 27 <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 /> 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 Lo .al Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name Phone ;y <br /> Address d2 , G City d <br /> Contractor' s Name �, License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMP NSATIO'N INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN F-1RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHL RINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION E7 PUMP REPAIR❑ PUMP REPLACEMENT <br /> .01 <br /> DISTANCE TO NEAREST: SEPTIC TANK O t-+ SEVER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIEn /[fir CESSPOOL/SEEPAGE PIT OTHER 4,e-2Z- z <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 Drilled Dia. of Well Casing `� f1C' <br /> Domestic/public Driven Gauge of CasingfL1 r11cef_/ <br /> Irrigation =Gravel Pack Depth of Grout Seal <br /> Cathodic Protection `Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br />'DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> — <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 CALjL FOR A GRQVT INSPECTION PRAOR TO GROUTING AND A FOAL INSPECTION. <br /> SIGNED TITLE: DATE: / <br /> DRAW PLO L N ON REVERSE SID <br /> PHASE I :�2 <br /> FOR T EPAR' USE ONLY <br /> APPLICATION ACCEPTED B ATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY� DATE INSPECTION BY DATE I <br /> Pf o z z/71� b <br /> 7 <br /> 1426_ Rev. ].2-7 " �'''� '` CaE3 I /78 _ 2M_ <br />