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�C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> =ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ,3 <br /> 1 Telephone: (209) 466-6781 <br /> Date Issued <br /> APPLICATION:,FOR WELL •CONSTRUCTION OR PUMP PERMIT - -Q-�"-2g, <br /> Thl,s Permit, Ex ires 1 Year From Date Issued <br /> �� Complete in Triplicate <br /> Application is hereby made to��the San Joag0 n. •.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 Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS <br /> UZIA, CITY/TOWN <br /> Owner's Name Phone <br /> Address - .Ci.ty_ <br /> Contractor' s Name Li censer <br /> --?L hone <br /> IS CERTIFICATE OF WORKMAN'S Cdr ENSATIO"i IidSURA"JCE ON FILE WITHSJLHD? YES 'VO <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN 0 RECONDITION ® DESTRUCTION <br /> WELL CHLORINATION 0 ---WELL .ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION M . PUMP REPAIR❑ PUMP REPLACEMENT [a y <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 Excavitiori <br />�--:Z—Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> irrigation I 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 -oflPump� N.P. �— <br /> PUMP- REPLACEMENT: 21-State Work Done <br /> —�, _ <br /> PUMP REPAIR: Q State Work Done i <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 /> gith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local. <br /> lealth District. Home owner or licensed agent's signature certifies the following: k. <br /> "I certify that in the perfd mance 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. " it <br />[ WILL CALL FOR A GROUT INSPECT' N_PR,14RTO GROUTING AND A FINAL INSPECTION. <br />;IGNED *kR4*P0T;P�LVtN <br /> TLE: DATE: <br /> REVERSE IDE <br /> FOR DEPARTMENT USE ON Y <br />'RASE I I <br /> IP PLICATION ACCEPTED BY DATE y .. <br /> 0DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION- " <br /> PHASE I I INAL INSPECTION � <br /> NSPECTI,ON BY DATE INSPECTION BY DATE <br /> 1 <br /> H 1426 Rev_ 12-77 , I-7tl nf. <br />