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t_ S'AN JOAQUIN. LUCAL-.HEALili U15'IXIL <br /> EQR <br /> FFIC£ US 1601 E. Hazel tone Ave. , Stockton, CA 95205 Permit No. <br /> Tel ephone: '(209G)'465-.6781 <br /> APPLICATION FOR WELL CONSTRUCTION,OR PUMP PERMIT Date Issued /Y 'T <br /> This. .Permit Ex ices 1 jY.ear° Froin Date: Issued <br /> ,. ;. Complete, In Tri pl i tate <br /> Application is hereby made to the. San Joaquin, Loca-1 Heal-thPDistrict ;for _a :permit to construct . ; <br /> and/or i- stat-lethe='work-herei:n 'described-: _ This :application-;is •made, in, compliance with San <br /> .?oaquin.-Co'u'nty . 1862 .and the .Ru.l,es and .Regulations of the. San. Joaquin :Local . Health <br /> District. <br /> oa� r �_ <br /> EXACT `STREET`"ADDRESS Lam' / - CITY/TOWN <br /> Owner's dame Phone �+ <br /> Address _Ci.ty. <br /> Contractor' s Name License Phone " Z <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAINCE ON FILE -WITH SJLHD? YES NO <br /> TYPE-OF WORK (Check) : NEW WELL 0— DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 -- <br /> PUMP INSTALLATION a PUMP REPAIR❑ PUMP REPLACEMENT Q <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 Gravel `Pack Depth of Grout Sea <br /> Cathodic. Protection A --Rotary : Type of Grout <br /> DisposalOther Other Information ; <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor wDoi ; <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> SN <br /> Describe Materia and Procedure <br /> 1hereby,certi fy that' I_-..have.,preparedLL this application -and that the work wi•1.1 '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 perswin such manner as to become subject to Workman's Compensation <br /> laws of Cal-ifornia. <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 2 AV <br /> E <br /> WRAW PLOT PLAN ON REV RSE SIDE <br /> FOR DEPARTMENT USE- ONLY <br />` PHASE I DATE <br /> APPLIGATiON ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION r PHASE III EINAL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY DATE — [. <br /> EH 1426 Rev. 12-77 7 8, - <br />