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r �.✓ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE E: T 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 9 o1,, <br /> Telephone: (209) 466-6781 <br /> �07, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ! 3.7� <br /> This: Permit Expires 1 Year From Date Issued <br /> Complete In Trip icate <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 /> .'oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 93 93 3 L.i CITY/TOWN <br /> Owner's Name :R&4*.acPhone <br /> Address S9 311 City <br /> Contractor' s Name License# *.v4-7 Phone <br /> 'S CERTIFICATE OF WORKMAN'S COMPENSATION INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION C9 PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CES�6L/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 Sea <br /> Cathodic Protection Rotary 'Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 4K,,e4, H.P. <br /> PUMP REPLACEMENT: []State 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 accordanc <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 FORA GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGN TITLE: DATE: <br /> (DRAW PLOT PiTN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEL <br /> ADDITIONAL COMMENTS: _r— <br /> PHASE II GROUT INSPECTION PHAS II FI INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> EH 1426 Rev. 12-17 loff78 2M <br />