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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> QR FFICE USE: 1601 E. Hazelton Ave.- , Stockton, CA 95205 Permit No. --''a-,-9L <br /> Telephone: (209,) 466-6781 <br /> APPLICATION FOR WELL 'CONSTRUCTION OR PUMP PERMIT Date Issued,?_.,/F-7� <br /> TKis Permit Ex ires .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 here Vn described. This appl-ication - 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 /> . �..�.,.- - L'���va'� s/��'r�v► <br /> EXACT STREET ADO DEC6 °' ` CITY/TOWN <br /> Owner's Name .�, .� Phone <br /> Address �13 e r -Y—, City 4.� i � <br /> Contractor's-Name, `..; __ Li ceiise (e Phone <br />' IS --C'ERT-TFTCATE,OF`WORKMAN'S -COMPENSATIO"! -1NS-URANCE -ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL[D DEEPEN ❑ RECONDITION ❑YDESTRUCTION[j <br /> WELL CHLORINATION 0 WELL ABANDONMENT [ OTHER [ th <br /> PUMP INSTALLATION [- PUMP REPAIRE3 - PUMP REPLACEMENT <br /> 11 S <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 'I.nformatlon <br /> Geophysical ( `�� Surface Seal I s Oiled by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP° REPLACEMENT: State Work Don <br /> PUMP REPAIR: State 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 FOR A T INSPECTIONPRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: r DATE: <br /> t ��R W PL T PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLYPHASE I <br /> ! <br /> APPLICATION ACCEPTED BY f DATE <br /> ADDITIONAL COMMENTS: <br />' PHASE II GROUT IN9PECTION PHASE III FINAL INSPECTION <br />' INSPECTION BY DATET INSPECTION BY DAT E449 f5=7g <br /> EH 1426 Rev_ 12-77 " ""'" - k 1 /78 2M <br />