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T SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR 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 —2_o— <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 /> .Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 4e_1",/—,4 e a- CITY/TOWN, <br /> ,Owner's Name r)` L )'Y Phone <br /> ;Address City <br /> Contractor's Name J�-Licens ` . Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSUR BICE ON FILE WITH SJLHD? YES �I <br /> TYPE OF WORK (Check) : NEW WELL Y�r DEEPEN C1 RECONDITION [] DESTRUCTION[ <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION Ra--- PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK �O EWER LINES PIT PRIVY " r <br /> SEWAGE DISPOS (FIELD �` CESSP OL/SE AGE PIT /�� OTHER r <br /> PROPERTY LIN PRIVATE DOMESTIC WELM PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial— <br /> Cable Tool Dia. of Well Excavation <br /> c-- Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public 4�—Driven Gauge of Casing /_9- <br /> Irrigation Gravel Pack Depth of Grout Sealr— <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor 1 �� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q 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 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 CA R A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED t DATE: <br /> �UKAW FLUION REVERV SIDE <br /> FOR DEPARTMENT SE ON Y <br /> PHASE I <br /> APPLICATION ACCEPTED BY rj-TDATE (,'/Z V/7 <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DA E ��� -1°� INSPECTION BY DATE <br /> EH 14 26 Rev. /78 <br /> 9/78 2M <br />