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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave,.:, Stockton, CA 95205 Permit No.zf-- ;5'6 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /� <br /> This Permit Expires 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 work herein described. This application' is made in compliance with San - <br /> Joaquin County Ordinance No: 1862 and the Rules dnd Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT. STREET ADDRESS 2 3 l CITY/TOWN <br /> Owner's Name - Phone .?��,?g��l-- <br /> ty /�sc <br /> Address 2 - Ci <br /> Contractor's Name 2 License#' Phone _ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO�� INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF� WORK (Check) : NEW WELL PQ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR O PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK_SSEWER LINES _<y' PIT PRIVY <br /> SEWAGE DISPOSA4 FIELD CESSPQOL/SEEPAGE PIT ____.OTHER <br /> PROPERTY LINE/O-f PRIVATE DOMESTIC WELL 'Ca - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL "' ! - CONSTRUCTION SPECIFICATIONS N <br /> Industrial Cable Tool . -Dia: of Well Excavation <br /> Domestic/private '� .-f'f 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 b <br /> k <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H • -SU <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> ` DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure <br /> C <br /> I hereby certify that I have prepared this application and that the work will be done in accord0 c+ <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 I WILL CALL FOR A GROUT " s EC 0 PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDd�h TITLE: DATE: <br /> azs- D W PL T N ON REVER IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> i .XPPLICATION ACCEPTED BY DATE -1 -7 <br /> ADDITIONAL COMMENTS: 61 L <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> kINSPECTION BY DATE INSPECTION BY DATE <br /> 1/78 <br /> EH 1426 Rev. 12-77 - =2M <br />