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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton ,Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> I Date Issued &_1 <br /> iAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permi.t ,Ex fres 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 the worklMherein described. This application is made in compliance with San <br /> ians, oF the San Joaquin .Laca} Health <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulat <br /> rDistrict. <br /> EXACT STREET .ADDRESS <br /> CITY/TOWN <br /> Owner's Name L Phone <br /> Address N City <br /> Contractor' s Name License#1�1,6hq , Phone S— I� _ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'N' INSURANCE ON FILE WITH SJLHD? YES 1140 <br /> i <br /> . TYPE OF WORK (Check) : NEW WELL-0 . DEEPEN CI RECONDITION [3 DEOTHER <br /> C <br /> WELL CHLORINATION WELL ABANDONMENT p OTHER 0 <br /> NER �1 <br /> I PUMP INSTALLATION ' rPUMP REPAIR❑ PUMP REPLACEMENT C! <br /> k - <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 1 <br /> _Domestic/private', Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of. Casing L <br /> Irrigation _**X_JGravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> ILT <br /> PUMP INSTALLATION: Contractor Ar ��--��� �� e'O <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ]State Work Done <br /> PUMP- REPAIR: QState Work Done ## <br /> t' DESTRUCTION OF WELL: ;Well Diameter QUI s AR oximate Depth <br /> Describe Material Procedure ve <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> with. San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca' <br /> CHealth District. Homellowner 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 INSPEC ION. <br /> SIGNEQ r TITLE:. 'DATE: <br /> iM DRAW PLOT PL N ON REVS S E <br /> FOR DEPARTMEN USE ONLY <br /> }PHASE I DATE <br /> :APPLICATION ACCEPTED 6Y <br /> ADDITIONAL COMMENTS: ell <br /> PHASE II GROAT INSPECTION PHASE III =FINAL INSPECT ON <br /> INSPECTION BY IN DATE INSPECTION DATE - Z" <br /> j <br /> [ Q <br /> rw ane n_.. -1 n '77 - <br />