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SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> �FICaE USE: P, 1601 E. Hazelton Ave. Stockton CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> Date Issued i-- -� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (ComTriplicate) <br /> plete In <br /> Application is hereby made toithe 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 'JoaquilnLocal Health <br /> District. <br /> EXACT STREET ADDRESS 014Y;/ M CITY/TOWN <br /> Owner's Name `, � Phone <br /> AddressCity r <br /> 'Contractor's Name Li cense#/y3,�y phone V41 <br /> IS CERTIFICATE OF WORKMAN'S CO"i NSR IQN INSURANCE ON FILE WITH SJLHD? YES Q <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION [:] DESTRUCTION[I <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHERf� <br /> PUMP INSTALLATION Q PUMP REPAIR R PUMP REPLACEMENT E3 <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES ,. PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCE5'SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> -5—dustrial Cable Tool Dia, of Wel Excavation r <br /> W Domestic/private Drilled Dia. of Well Casing <br /> Z. Domestic/public ' - Driven - ' Gauge�-of�-Cas-tn-g- q -R- W- <br /> Irrigation Gravel-: Pack Depth of Grout Sea <br /> Cathodic Protection Rotary- Type of Grout <br /> L ' Disposal Other Other Information <br /> Geophysical x Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: p State Work Done LJ <br /> PUMP REPAIR: 1c]State Work Done <br /> ff <br /> DESTRUCTION OF WELL: Well Diameter - �— U � Approximate Depth <br /> Describe Material and Procedure <br /> I <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. " I <br /> I WILL CALL FOR A GROUT INSPECTIQN,,PRWRSTONGROUTING AND A'FINAL INSPECTION. A <br /> SIGNED -ITLE: DATE: e t <br /> ,VPLOT PLAW ON REVERSE SIDE) . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �. <br /> APPLICATION ACCEPTED BY DATE X-1-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTIQN BY DATE INSPECTION BY DATE - 7 <br /> EH 14 26 Rev. 9/78 >! . . ,._ 9/78 2 <br />