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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rFI-.CE'USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: ,, (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issueft 2_ 4 19ZO <br /> This Permit'Ex :i re's 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 /> and/or install the work -herein described. This application is made in -compliance withSan <br /> Joaquin County Ordinance No. 1862and the Rules and- Regulations. of the .San oaqu ' Loc al . Health <br /> District. <br /> � <br /> EXACT STREET ADDRESS -.., CITY/TOWN <br /> Owner's Name Phone } <br /> i <br /> Address D City 1 ffO4 <br /> Contractor' s Name / License# L&-7)AY Phone <br /> IS CERTIFICATE OF WORKtIAN'S COM ENSATION INSURA"ICE ON FILE WITH SJLHD? YES 1C ;i0 <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN ❑" RECONDITION C3 DESTRUCTION[j <br /> WELL CHLORINATION 0 WEL A MENT 0 'OTHER 0 , <br /> PUMP INSTALLATION M MP REPAIR PUMP,REPLACEMENTEJ <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 k <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of We11 Excavation <br /> Domestic/private Drilled Dia. of Well Casing _ t,,` <br /> Domestic./,p.ublic Driven Gauge of Casing' <br /> Ea r.rigai;ionr Gravel Pack Depth of Grout Seal <br /> Cat -di-c -Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Inst511ed : <br /> PUMP-..I.N TALLATION 7�Contractor —_. --'Type-of- Pump .P. <br /> PUMP, REPLACEMENT: QState Work Done " <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ana Proce ure ; <br /> d <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 mariner as to become subject to Workman 's Compensation <br /> laws of California. , <br /> I WILL CALL FOR A GROUT I T ON; PR•I R:70:GROUTING AND A FINAL INSPE ION. <br /> SIGNED TITLE: , DATE: <br /> W PL T 'N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />)HASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: ` <br /> iPHASE. II. GROUT INSPECTION PHAS ''IiT iNA INSPECTIO <br /> INSPECTION BY DATE INSPECT=I.ON BY E <br /> IH 1426 Rev:- 12-77 e , /7 9 0M 1 <br />