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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.>g'_/ty g f <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 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 with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> 'district. G 9:A <br /> EXACT STREET ADDRESS D Gt/ CITY/TOWN ' R <br /> Owner's Name Phone_34 <br /> Address $r GrJ �,y® r�,c �A, /�Q Ci <br /> Contractor's Name_ ,� _ License# 3 Phone 3 4, -J' <br /> IS CERTIFICATE OF WORKMAN'S COMIPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES ;— 11,10 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT O OTHER 0 � W <br /> PUMP INSTALLATION §R PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 1.2d / SEWER LINES l_S;d " PIT PRIVY- <br /> SEWAGE DISPOSAL FIELD/ 7S--' 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 CasingT <br /> Domestic/public Driven Gauge of Casing l Z. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: [I State Work Done <br /> f <br /> PUMP REPAIR: []State Work Done <br />. DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure - <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 manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CAL R PA GROUT I SPECTION PR R TO GROUTING AN INAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DR W PLOT PL N ON REVERSES E <br /> FOR DEPARTMENT-USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /0� Il� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION! PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE J/ <br /> 1H 1426 Rt-v_ 12-77 1/78 2M <br />