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t. SAV JOAQUIN LOCAL HEALTH DISTRICT <br />'' FRICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL� CONSTRUCTION OR PUMP PERMIT Date Issued�( <br /> This Permit Ex ices 1 Year From Date Issued <br /> Complete In Tri pl icate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> f and/or Linstall the work herein described. This application is made in compliance with San <br /> w Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local HealtK <br /> District. <br /> EXACT STREETADORES7/// CITY/TOWN <br /> Owner's. Name I--, Phone <br /> Address City <br /> i License# Phane <br /> Contractor's Name L� <br /> IS CERTIFICATE OF- WORKMAN'S COMPENSATION INSU ANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 � <br /> PUMP INSTALLATION CI PUMP REPAIR❑ PUMP REPLACEMENT Q �+ <br /> DISTANCE TO NEAREST: SEPTIC TANK.5e) '-f SEWER LINES I-J PIT PRIVY T-- -� <br /> SEWAGE DISPOS FIELD CES�L/SEEPAGE PIT -- OTHER -- <br /> PROPERTY LINEC�+PRIVATE D­6MESTIC WELL- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 16 4 <br /> Domestic/private Drilled Dia. of Well Casing 0 <br /> Domestic/public Driven Gauge of Casing <br /> k Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection y <br /> Ljotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H• • <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter t.. Approximate Depth <br /> Describe Material and Proce ure ,- <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc <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 perf6rmance,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 C FOR & GROUT SP TI RIOR TO GROUTING AND A FINAL INSPECTION., <br /> SIGNE TITLE: At DATE: <br /> RAW PL T N ON REVERSE IDE <br /> FOR DEPARTMFNT USE ONLY <br /> PHASE I . ._ . - _-. .- P - _ - <br /> APPLICATION ACCEPTED BY r� DATE 0, 97 <br /> ADDITIONAL COMMENTS: <br /> ` <br /> PHMkfAI GROUT INSPECTION PHASE_1!1,FJ$AL INSPECTION <br /> , INSPECTION BY DATE — : INSPECTION BY DATE <br /> k EH 1426 Rev. 12-77 1/78 2M_- <br />