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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FE�FFICE 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 7-�i�7 <br /> C"r4orn49 7, This Permit Expires 1 Year From Date Issued <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 /> g <br /> ,-I <br /> Oaquin <br /> an" ,'oaquin County Ordinance Nu. 1862and-th.e Rul s ,and Regul tions f the San Joaquin Local Health <br /> District. LL % d Gc/C <br /> X. <br /> FEXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name Phone <br /> Address 6 4.rl City �ae , : - <br /> Contractor's Name <br /> License# jjj -7, rPhone 6�6-)- 26. ZZ <br /> IS CERTIFICATE OF WORKMAN'S CO"•1 EJSATIO"1 IPISURA*10E. 'OPl FILE WITH SJLND? YES S40 <br /> . TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION Q DESTRUCTION❑ <br /> WELL CHLORINATION p WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR 5D PUMP REPLACEMENT Q <br /> ! DISTANCE TO NEAREST: - SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> k PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> x 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 `S <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:. Contractorj <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: []State Work. Done <br /> t PUMP REPAIR: - (; .State Work DoneP&ce Xamrd <br /> DESTRUCTION OF WELL: Well Diameter, Approximate Depth <br /> rDescribe Materia. an P.roce ure <br /> I hereby certify that I have, prepare8,.,thi's application and that .the work will be ;done in accordant <br /> 1with San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <br /> kHealth District. Home owner ,or licensedagent's signature certifies the following: <br /> "I certify that in.,the perform6nce 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 CAL FOR A GROUT INSPECT NPR 0 0 GROUTING, AND A FINAL INSPECTION, <br /> D 4 ,TLF: DATE:SIGNELN O REVERSE SIDE) <br /> ' <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.aj DATE <br /> >ADDITIONAL COMMENTS: c <br /> PHASE II GROUT INSPECTION' PHASE III FINAILINSPEeTIO4 <br /> INSPECTION BY: DATE INSPECTION BY DATES ;Z'Y, <br /> EH, 1426 Rev.- 12-7.7-. <br /> �"r/78 .e. 2M <br />