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SAN JOAQUIN LOCAL HEALTH D1S]RlCT <br /> FFPCE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. -717-9 7 <br /> Telephone: (209) 4'66-67811 <br /> APPLICATION FOR 'WELL Date Issued'? //-?9 <br /> ELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ices 1 Year From Date Issued <br /> Complete In Triplicate <br /> 4 Application is hereby made to the San Joaquin Local Health Dist riIct for a permit to' construct <br /> and/or install the work herein described,.: This application .is; made in compliance.'with San <br /> L'oaquin County Ordinance No. �1862 and the Rules and Regulations, of the San Joaquin -Local 'Health <br /> District. <br /> EXACT STREET ADDRESS !��]�,. oR CO -CITY/TOWN..�_ <br /> Owner's Name 17 <br /> Phone — �- <br /> Address .g t City <br /> Contractor' s Name t <br /> License 8-'c[ / Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO1111 INSURAPdCE ON FILE WITH SJLHD? YES NO <br />' TYPE OF WORK (Check) : NEW WELL Q DEEPEN ❑ RECONDITION [] DESTRUCTION <br /> WELL CHLORINATION p WELL ABANDONMENT Q OTHER A . <br /> PUMP INSTALLATION, X PUMP REPAIR(--] PUMP REPLACEMENT F] <br /> DISTANCE <br /> , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESIL-J`i ka-PJT.x.PRIVY <br /> SEWAGE DI.SPOSAL FIELD_ CESSPOOL/SEEPAGE PIT OTHER !- r <br /> PROPERTY LINE -. PRIVATE DDNfESTTC ELL :7PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OFWELL . CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> � V _Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Dri"Ven Gauge of Casing <br /> Irrigation '�Grave'l Pack Depth of Grout Sea i <br /> Cathodic Protection ' Rotary =_. Type of Grout <br /> Disposal N� Other Other Information <br /> Geophysical Surface Seal Installed by: ' t <br /> PUMP INSTALLATION: Contractor <br /> Type_of Pum 17H. ; <br /> PUMP REPLACEMENT-, Q State Work Done <br /> PUMP REPAIR: �OState Work Done <br /> DESTRUCTION OF WELL: Wel 1--Diameter <br /> Approximate Depth 1 <br /> Descr%e- MateriaTan2 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 CALLF.QR, PrhGROUT ANSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. ; <br /> SIGNE TITLE: 'DATE: 7- <br /> (DRAW PLOT L N ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY i <br /> 7 <br /> APPLICATION ACCEPTED BY € DATE x7-16-7 1 <br /> ADDITIONAL COMMENTS : t f <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY "4W-9— DATE�V, -7f <br /> tco <br /> EH 1426 Rev. '12-77 _ i 1-791-9M <br />