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r _ SAN JOAQUIN LOCAL HEALIH U1JIKiL.1 <br /> _FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton,- CA 95205 Perini~ No.��'�� <br /> Telephone: (209) 466-6781 <br /> NAY 2 4 ISIS <br /> �.. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issue <br /> This Permit,Ex ires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made ;to the San Joaquin Local Health District far apermit 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. v. <br /> 1 XACT STREET ADDR S CITY/TOWN Phone �Y3Owner's Name <br /> ' <br /> Address . . City <br /> Contractor' s Name <br /> may%~ License phone :)"4 <br /> IS CERTIFICATE OF WORK11AN'S COMPENSATIOi1 I"JSURA"10E ON FILE WITH SJLHD? YE9--- NO <br /> TYPE OF WORK (Check) : NEW WELL[l' DEEPEN ❑ RECONDITION [D DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ . <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENTI�� Q <br /> 1 DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL £ � ,3, , ,: CONSTRUCTION SPECIFI TALONS <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 9 i <br /> Disposal' " ' . ~ Other Other Information <br /> Geophysical - Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor -. <br /> [ Type of Pump 57- H.P. .� <br /> PUMP REPLACEMENT: 53State Work Done <br /> PUMP REPAIR: ❑State-Work Done ` <br /> DESTRUCTION OF WELL: :Well =Diameter -Approximate Depth <br /> Describe Material and Procedure <br /> f I hereby certify that I have prepared this application and that the work will be ;done in accordan <br /> r with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <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 INSPECTION%PRIOR TO GROUTING AND A FINAL`INSPECTION. <br /> SIGNED TITLE: DATE: 55ad ?Y <br /> r _ (_DRAW PLT PLTIT ON REVERSE SIDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY a DATE "A44 '7 ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE 7-7 7d.l <br /> rp ]ra9A Ro114 1 9_77 _ - --.1/78 2' <br />