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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> R ,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone:'. (209); 466-6781 <br /> APPL:IICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -r <br /> Theis Permit 'Expires 1 Year From Date Issued <br /> Complete In' Triplicate 7 7- 03 , <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the wor.k. herei-n 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 /> ; <br /> EXACTSTREET ADDRESS _3�'j�S ��r� �� CITY/TOWN 4<y <br /> Owner's Name phone -- <br /> 2224 <br /> Address City <br /> Contractor's Name x License Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"l IMSURA"SCE ON FILE WITH SJLHD? YES NO <br /> £ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER FJ -� <br /> PUMP 'INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANKa� SEWER LINES — PIT PRIVY S <br /> SEWAGE DISPOSAL FIELD _'CESSPOOL/SEEPAGE PIT OTHER � <br /> PROPERTY LINe'6!4RIVATE DOMESTIC WELLS 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 <br /> - <br /> p ; Gauge of Casing <br /> Irrigation Gravel Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instar by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. . <br /> PUMP REPLACEMENT:. ❑State .Work Done <br /> PUMP REPAIR: ❑State'Work Done <br /> .4. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an- !Proce ure <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: q <br /> I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ any persontih such manner as to become subject to Workman's Compensation <br /> laws of Cal ifornia. "%,. , <br /> I WILL CALL-FOR A ROUT "SPECTWVPRIOR TO GROUTING AND A FINAL INSPECTION. 1 <br /> SIGNED P TITLE: - DATE: .;, _ <br /> i DR W PL T L ON REVERS DE <br /> i F R JDEP RTMENT USE ONLY <br /> I� PHASE I <br /> APPLICATION ACCEPTED BY DATE r <br />' ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE, 7-7-7P <br /> EH . 1426 Rev.. -12-77 �? � ' �' 1/78 2M <br />