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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued , -,,;4-2y, <br /> This 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 peconstruct <br /> and/or install the work herein described. This application is made in compliance with San <br /> loaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. AAO <br /> EXACT STREET ADDRESS �✓� -�C— CITY/TORN 0 <br /> Owner' s Name R4k 0 •r7,,e vc7/0� Phone - 21 7 <br /> Address Ci ty t/ Po,� <br /> Contractor's Name—n_ i , ._...,.,._„ License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN I'MSURA"!CE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ T <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ 0� <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 WELL7 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavtion <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 Information, .. ' <br /> Geophysical Surface Seal Installed by:� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -,s;-'u b IL t— H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work 'one <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 C FOR A GROUT IN PECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE.: �. �.� DATE:(URAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPA MENT USE ONLY <br />,APPLICATION ACCEPTEDBY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />'INSPECTION BY DATE INSPECTION BYGr/ DATW��� <br /> EH-1426. Rev. 12-77 x �`' ---- - t , ��� 11'7 <br />