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SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave.., Stockton, CA 95205 Permit No. i� 7 <br /> � Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued IoZ <br /> i <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 /> ; <br /> and/or install the `work herein described. This application is made -in compliance with San <br /> .'oagjin County Ordinance No. 1862 and the Rules and Regulations of the. San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS_ 3 ,�, ' •EQ RSP —. CITY/TOWN <br /> Owner' s Name -rj_y- r Phone <br /> Address ��. City . . . <br /> Contractor's Name - j.Oj//!/(I� 1j��(p a LicensePhone <br /> IS CERTIFICATE OF WORKMAN'S Cf)MPENSATIO"i INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMPINSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ 4� <br /> 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 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 .i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal !; Other Other Information .-- <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor r <br /> Type 6f Pump . H.P. <br /> LYS.... -- <br /> PUMP REPLACEMENT: []State lWork D e <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter . Approximate Depth J <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 owne`i� r 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 i-nl�such manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CALL F A GR UT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: '2j <br /> iM DRAW PLOT PL N~-ON REVERSE SIDE <br /> iM FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �M f DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />'INSPECTION BY OATE INSPECTION BY DAT <br /> E-H_1.426 '=Rev. .12=77 _ 1/78 2M. <br />