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/ MN JUHQU 1 N LUGAL HLAL I H U 1� 1 K1 U 1 <br /> FFICE USE: Y 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.F- I <br /> Telephone: (209) 466-6781 <br /> I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made. to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> i-caqu in County Ordinance 1,o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> J15tr'Ct• �01100 CC <br /> EXACT STREET 1ADDRESS CITY/TOWN <br /> Owner' s Name Phone <br /> Address City <br /> Contractor' s Name License#f6-ZJ73 Phone__ d�} f�. <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATITN INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLE] DEEPEN ❑ RECONDITION ❑ DESTRUCTI'ON[j <br /> WELL CHLORINATION ❑ WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION [] PUMP REPAIR❑ PUMP REPLACEMENT ❑ Q <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 Excavation <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 H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: Q 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 Warkman's Compensation <br /> laws of California. " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE: DATE:Alp _p- � <br /> W PLOT PIAN ON REVERSE SIDE <br /> FOR DEPARTMENT, USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE,,i4a /42 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY tan & - DATE INSPECTION BY DATE a.-a$•19 <br /> EH 1426 Rev. 12-77 1/78 2M <br />