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I +/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ICE USE.,, 3601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <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 .for a permit- to construct <br /> and/or install 'the work "Iherein described. This application is. made in compliance with San <br /> U'oaquir CountyOrdinance No. 1862 and the Rules and Regulations of the San Joaquin .Local Health <br /> District. F <br /> EXACT STREET 'ADDRESS: 'i�. as� tS�`- CITY/TOWN <br /> Owner' s Name. - I <br /> Phone <br /> Address CS'd` Ci t <br /> Contractor's Name T �� Li cense#_l -:21A---Frhone��• ��� f <br /> f I5 CERTIFICATE OF WORKMAkN'S COPi dSATIO"a INSURANCE ON FILE WITH SJLHD? YES NO <br /> STYPE OF WORK (Check) : NEW WELL b DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION p WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION [3 PUMP REPAIR 4 PUMP REPLACEMENT Q T <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY a <br /> SEWAGE DISPOSAL; FIELD_ CESSPOOL/SEEPAGE PIT OTHER <br />' PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> t 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/publicDriven • Gauge of .Casing <br /> Irrigation �� Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> DisposalI[ntractor Other Other Information <br /> Geophysical i Surface Seal Installed by: , <br /> - I <br /> PUMP INSTALLATION: CI <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: I State Work Done <br /> PUMP REPAIR: ]State Work Done . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure <br /> II I <br /> I hereby certify that I have prepared this application and that the work will be done in accordanr <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 FOR A GROUT INSPECZIOB P914RJO GROUTING AND A FINAL INSPECTION.'" <br /> SIGNS TITLE: eV%-r DATE: <br /> RAW_-PLOT__PLAY ON REVERSE SIDE)___ '. <br /> a <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> � . <br /> APPLICATION ACCEPTED BY 4, DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE-,JJJ .FINAL INSPECTION <br /> INSPECTION BY IN DATE INSPECTION BYE DATE —17`?S--- ; <br /> I <br /> zEH 1426 Rev. 12-77 i 8 <br />