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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit Na, — /Z <br /> �`�'- Telephone: .. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7—tea-7 <br /> This Permit Expires I 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•lthe work herein described. This application is made in compliance with San <br /> Joaquin"'County Ordinance No. 1862 larld, thes and Regulations of the San Joaquin Local Health <br /> 'District. <br /> EXACT .STREET ADDRESCITY/TOWN <br /> ,Owner's Name Phone <br />'Address o. d : City cc <br /> Contractor's Name Li cense# 141,02_ Phone --S5:7 <br /> IS CERTIFICATE OF WORKMAN'S C0",PENSA IO"! INSURANCE ON FILE WITH SJLHD? YES P10 <br />�rTYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ RECONDI.TION ❑ DESTRUCTION❑ � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHERfJ _ ---- 9-01 <br /> PUMP INSTALLATION ❑ 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 /> 4 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Casing _ _ <br /> Domestic/public Driven Gaugeiof Casing zz <br /> Irrigation Gravel Pack' Depth of Grout Seal I:E2 <br /> Cathodic Protection IRotary Type of Grout <br /> Disposal =Other Other Information_ <br /> Geophysical y Surface Seal Installed by':' IL-. - <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump, ,< - H.P. <br /> PUMP REPLACEMENT: E]State Work Done <br /> PUMP. REPAIR: ❑State Work Done <br /> t DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 <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 , StateLaws , 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 suchiman-ner as to become subject to Workman's Compensation <br /> laws of California." <br /> I WILL CA FN A GROUT IN PECTION..,PRIOR TO GROUTING AND A,FINAL INSPECTION. <br /> SIGNED .. TITLE: 4�4v-311� DATE: <br /> (DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DJEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -71Y-0117'r <br /> ` ADDITIONAL COMMENTS: { <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> = INSPECTION 8Y DATE INSPECTION BY _� DATES' <br /> �Pu 1/199 oo., °` 7_77.:. -1/78 2M <br />