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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued G11, 7i <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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET AD SS L CITY/TOWN <br /> Owner's Name Phone 36 Y-37/ Q <br /> Address rPo City <br /> Contractor's Name Li cense# &X323 Phone 3�_ F-1-0,C <br /> IS CERTIFICATE OF WORKMAN'S COMIPENSATIO'! 111SURAINCE ON FILE WITH SJLHD? YESy NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT a OTHER 0 V <br /> PUMP INSTALLATION ❑ PUMP REPAIRIa PUMP REPLACEMENT IJ <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 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_..... - - H.P. 7_ <br /> PUMP REPLACEMENT: r]State Work Done <br /> PUMP REPAIR: 55tate 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 OR A GROUT NSPECTIO PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> _�RAWLOT PLAN ON REVERSE Si <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �f <br /> APPLICATION ACCEPTED BY DATE c1J ~_`_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYE' DATE /1_ <br />_EH--1426 Rev_ 12-77 . 1 /78 2M <br />