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#� 5AN JUAQUiN LUUAL HtALIH UiJ1KILI <br /> K� FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No7 <br /> Telephone: {s09}'466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Hate Issued`/� -7 <br /> i <br /> This Permit Expires l 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 /> 1 arid/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 CITY/TOWN <br /> Owner' s Name Phone - 7 <br /> Address City. <br /> Contractor's Name License# Phone 3 S <br /> ':S CERTIFICATE OF WORKHAN'S QMPENSATI011`1 I'JSURA"dCE ON FILE WITH SJLHD? YES "JO <br /> TYPE OF WORK (Check) : NEW WELL54 DEEPEN Q RECONDITION ® DESTRUCTION[] <br /> WELL CHLORINATION D WELL ABANDONMENT O OTHER El <br /> t PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO �NEAREST: SEPTIC TANK 7.L� SEWER LINES' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD/dp-' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - RRIVATE,-�DOMESTI-C�WELL SL_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL'_ �f CONSTRUCTION SPEC"IFICATIONS <br /> Industrial _Cable Tool Dia. of Well Excavation-/ <br /> Domestic/private Drilled Dia,- of Welkl ..Casing'• A` k , <br /> i Domestic/public Driven Gauge of ,Casingll <br /> Irrigation Gravel Pack, Depth--of-Grout Seal <br /> Cathodic Protection Rotary 4Ty_pe of Grout <br /> Disposal Other Other Information .,: <br /> Geophysical --Surface Seal Installed 'b An- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �H.P,,. <br /> PUMP REPLACEMENT: r] State Work Done -' <br /> { - 7 c`!• _ <br /> PUMP REPAIR' Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> is Describe Material and Procedure t <br /> I hereby certify that I have prepared this a lication d that the work will be done in accordan <br /> r with San Joaquin County Ordinances , State Laws; and Rules and Regulations of the San ,Joaquin Loca <br /> t 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 /> I not employ any person in such manner as to4kecome�subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CALL =FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: cd -7 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ' APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> • PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE ^f.?_. INSPECTION BY DATE . 7� <br /> s FH• 101;— PPV 12-77 -- _ 1 /7 _ 2M <br />