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4°wwe SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR FFICE USE: 1601 E-. Hazelton Ave. , Stockton, CA 95205 Permit No. 7�X77 <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 herein described. This application is made in compliance with San <br /> kloaQuin County Ordinance No . 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS GITY/TOWN <br /> Owner' s Name b=morp Phone <br /> Address City �' -r e <br /> Contractor's Name '' C] Li cense#! ?y, Phone_ 7 6 <br /> IS CERTIFICATE OF WORKMAN'S COMPEr ATIO'N INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ T RECONDITION ❑ DESTRUCTION E] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER <br /> PUMP INSTALLATION ❑ PUMP REPAIR[R PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY N <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL -J <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 Ip.,stalled by: <br /> PUMP INSTALLATION: Contractor _39�� I,^ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: OState 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 CALL FOR A GROUT P£ IO R TO QJROUTING AND A FINAL INSPECTION. <br /> SIGNS %0011T,ITLE: &-.r, DATE: (,A7 <br /> �DRAW PLOT PLAN ON REVERSE SID£ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7fS <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE �T INSPECTION BY A::P DATE -14 <br /> EH 1426 Rev. 12-77 - _ 1178 2M-J <br />