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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. , 3& <br /> Telephone: (209) 466-6781 <br /> -� Date Issuedz . <br /> . APPL,ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (Comp1ete .In Triplicate) . <br />• Application 'is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or installthe 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 /> a <br /> District. *.'• � i <br /> EXACT STREET-ADDRESS e, , .A/ CITY/TOWN -SMe <br /> Owner's Name a =E' 7 Phone / t <br /> Address z!& z City_ S 2e,K'o1✓ <br /> Contractor's Name License# Phone ' <br /> IS CERTIFICATE OF WORK'1AN'SlCOtiPENSATION INSURANCE ON FILE WITH-SJLHD? YES O <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN ❑ RECONDITION ® DESTRUCTIONI <br /> WELL CHLORINATION Q /WELL ABANDONMENT O OTHER Q <br /> PUMP INSTALLATION M PUMP REPAIR 0- - -' PUMP REPLACEMENT ❑ v ' <br /> DISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PI�� OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL- PUBLIC D ESTIC WELL <br /> INTENDED USE" y TYPE OF -WELL_, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well NEavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> ' Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout 'Sea <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. <br /> PUMP REPLACEMENT:.':' State Work Done <br /> PUMP REPAIR: O State Work Done <br /> bDESTRUCIION OF WELL: Well Diameter '' Approximate DeptFt_ZQ �-t <br /> Describe Mate'rial and Procedure r� ry ' ��✓ <br /> x e: <br /> CAP, <br /> �P hereby certify that I have prepared this application, and that' the work;wi,l l° be done i n accordanc <br /> with San Joaquin County Ordinances , State Laws , and Rules and 'Regulations of. the San qu n'°.%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 'CAL FOR 0 INSPECTION PRIOR TO GROUTING AND A FINALv:INSPECTION. <br /> ' S'IGNED TITLE: ATE: ¢ !.� <br /> D P . L N ON REVERE SIDE <br /> R DEP R-T USE ONLY <br /> PHASE I <br /> Y:t <br /> (APPLICATION ACCEPTED BY ' ': DATE <br /> ADDITIONAL COMMENTS: " <br /> PHASE II GROUT'.INSPECTION, `�.,-.- PH rEI L INSPECTION <br /> `.INSAECTION BY : `. .DATE INSPECTION Y DATE L -Za`� <br /> EH L1426 Rev. 9/7.8::` _ 9/78_ .. � M <br />