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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P=FFICE USE: V/1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7,5-/,/,g3 <br /> Telephone: (209) 466-67812 Y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/g a Wig' <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. <br /> EXACT STREET ADDRESS CITY/TOWN�� <br /> Owner's Name 11 CoK Phone 3 —(,g a <br /> Address City:� r Wc_ l <br /> Contractor's Name , C-0 - Li cense# Phone'a 5 L(. 1 _ <br /> IS CERTIFICATE OF WORKr1AN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES X,--' '40 <br /> TYPE OF WORK (Check) : NEW WELL4!SL DEEPEN ❑ RECONDITION ❑ DESTRUCTION[n 0 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION-M PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> r <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 /> omestic/private Drilled Dia. of Well Casing Llf <br /> Domestic/public Driven Gauge of Casing S \ ,c <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 by: <br /> PUMP INSTALLATION: Contractor �, �� C <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 become subject to Workman' s Compensation <br /> laws of California. " <br /> I WILL CALL FOR GR WT 15§PECTION PRIOR TQ GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> W PLOT PLAN ON REVERSES E <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B;4:;;,,, DATE 1_r2> —� <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT I SPECTION PHASE III FINAL INSPECTIO _ <br /> INSPECTION BY DATE INSPECTION BY FATE <br /> EH 1426 Rpv_ 12-77 __-___. - .. .... _ 1/78 <br />