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Al-1 SAN JOAQUIN LOCAL/HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. Stockton, CA 95205 Permit No." 7 -� <br /> Telephone:- (209)-466-6781 Date Issue'd,5-3t-?.9 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> I n <br /> '(Complete Tri pl'icate), <br /> Application -is. hereby made to the San Joaquin Local Health �Distvict for a permit to construct <br /> and/or_instalT 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 S /J� CITY/TOWN Q <br /> Owner's Name . _ _ Phone_- <br /> Address <br /> Contractor's Name License# - i _ Phone•` yr 4 <br />` -TS CERTIFICATE -OF WORKMAN'S mm INSURAINCE, ON FILER WITH SJLHD? YES,• 0 � <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN ❑ • RECONDiTiON d DESTRUCTION(WELL CHLORINATION D WELL ABANDONMENT 0 OTHERFJ <br /> r PUMP .INSTALLATION E,�j PUMP REPAIR CI PUMP REPLACEMENT-[] <br /> N STANCE TO NEAREST: SEPTIC TANK SEWER LINES . ,PIT PRIVY <br /> ' SEWAGE DISPOSAL FIELD CESSPOUL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL—t ---- PUBLIC DOMESTIC WELL <br /> i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS- <br /> Industrial m Cable Tool- Dia. of Well Excavation - <br /> 1.. :_�Domestic/privateDrilled Dia, of Well Casing <br /> Domestic/public _ = :Driven 4 Gauge 'of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea y <br /> Cathodic Protection. Rotary s. Type of Grout <br /> Disposal Other Other Information <br /> -� Geophysical Surface Seal Insta ed b --k <br /> PUMP- INSTALLATION: Contractor a. <br /> Type of Pump , H.P. y <br /> 1 PUMP REPLACEMENT: E]State Work Done <br /> PUMP „ RState Work Done mourns - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> he'reby certif that I have prepared this application and that the work will be done in accordant <br /> ' with San Joaqu-in County Ordinances , State Laws, and Rules and Regulations of•the-San--Joaquin Local <br /> jHealth 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 CALL, FOR A GROUT INSPECTION PRIOR TO GROUTING AND'A FINAL. INSPECTION.- <br /> SIGNED iTLE: DATE: <br /> fL LDRAW PL0 T PLRNON REVERSE .SIE <br /> OR DEPARTMENT USE ONLY - <br /> PHASE I <br /> ; APPLICATION ACCEPTED BY DATE d" <br /> ADDITIONAL COMMENTS: <br /> PHASE II f4ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 40 <br /> EH 14 26 Rev. 9/78 M9/718�' M <br />