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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. - <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ©ate Issued S� <br /> (tomplete , 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 1 -3 r CITY/TOWN' 2i�-� <br /> Owner's Name AS . M& Phone 1'4!5 Vis` <br /> Address City S' u <br /> Contractor's Name 1 v,,,� License#�� Phon� rf - <br /> IS CERTIFICATE OF WORK"tAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES O . <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN ❑ RECONDITION ❑ DESTRUCTION EJ i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER El <br /> PUMP INSTALLATION C] PUMP REPAIR❑-.. PUMP REPLACEMENT 9+-- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , PIT PRIVY C <br /> SEWAGE DISP SRL MELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DORE5TIC WELL PUBLIC D MESTIC MEL W <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 /> L---I-rrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Sdrface Seal Installed <br /> PUMP INSTALLATION: Contractor A- <br /> Type of Pump c <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ` <br /> Approximate. Depth <br /> Describe Material and Procedure <br />- I hereby certify that I have prepared this applidation 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—Comp'ensati.on-�.,.�.- <br /> laws of Cal ifornia.-". - - --� -p- <br /> r <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A, FINAL_INSPE.CTI.ON•.- x�- -- -r <br /> SIGNED--. v — - TITLE:,--4/,C,/ DATE: <br /> D DACMD T L N ON REVERSE SIDE <br /> PHASE I <br /> R DEPARTMENT USE ONLY <br /> A PLT ATION ACCEPTED BY Z�,/ DATE /-7 <br /> ADDITIONAL COMMENTS: 77 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE& 1�t <br /> EH 14 26 Rev. 9/78 9/78 2M <br />