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SAN JOI�QUIN ;.UCAL HEALTH UISFRIUl- <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit .No. 21- w-A <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELD CONSTRUCTION OR PUMP PERMIT Date Issued - 7 <br /> This Permit Ex ires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application i 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 /> Joapa�n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESSLZI:z <br /> Owner' s Name Phone <br /> Address City <br /> Contractof'-s-Name " License# / Phone �Z�/Q 3,Z <br /> IS CERTIFICATE OF WO KMAN'S COMPENS 1IO-N INSURANCE Oli FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION [2 DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [] \A <br /> ' r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY S <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIMS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> estic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge�of`Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �-ary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <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 beca subject Workman' s Compensation <br /> laws of Califo .nia. " <br /> I WILL CALL F GROUT INSPECTION P R TO GROU ING AND A F AL INE ION. <br /> SIGNED ITL : r D E: <br /> (DRAWPLOT PLAN ON RE SE SIDE <br /> FOR DEPARTMENT SE ONLY <br /> PHASE I �- <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE, 11 GROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BYC;. DATE INSPECTION BY DATE <br /> EH 1426 Rev. 12-77" 1/78 2M <br />