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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> r� This Permit Expires 1 Year From Date Issued 1",4/1- Ta D 4,-;v,cR <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 /> ,'oanuin County Ordinance 1,o. 1862 and the Rules and Regulations of the San Joaquin Local Health , <br /> District. \. <br /> EXACT STREET ADDRESS ��.��/ �c <br /> l�uca� CITY/TOWNF-S�A 60AI <br /> Owner' s Names PhonewS�J� 0313____ <br /> Address City <br /> Contractor's Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHCORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 6C)ar SEWER LINES PIT PRIVY 0 � <br /> SEWAGE DISPOSAL FIELD 6Z / CESSPOOL/SEEPAGE IT d 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 h <br /> Irrigation Gravel Pack Depth of Grout SLsal— <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor le7 <br /> Type of Pump � �� -e - H.P. /O - <br /> PUMP REPLACEMENT: EJState Work Done <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 RR A G50YZ INSP CTION PRIOR TO GROUTING ANDA FINAL INSPECTION. <br /> SIGNED TITLE:. - DATE: -A-- <br /> DR W PLOT PLAN ON REVERS SIDE <br /> FO DEPARTMENT USE ONLY � � <br /> PHASE I / <br /> APPLICATION ACCEPTED BYlir/ DATELZ�— <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE ,c/,¢ INSPECTION BYDATE <br /> LEH 1426 Rev, 12-77 C35 1 <br />