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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No._j --K--( 1� <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT' Date' Issued <br /> This Permit Expires I 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 Phone <br /> Address R City <br /> Contractor's NameLicense# U Phone ZO 3 <br /> IS CERTIFICATE OF WORKMAN'S COMPEi' ATIO'N INSURANCE ON FILEtWITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN p RECONDITION-Q DESTRUCTION C3 <br /> OR <br /> WELL CHLINATION E] WELL ABANDONMENT 0 OTHER <br /> I PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT Ej <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Q <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> • PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC �J <br /> Industrial Cable Tool Dia. of Well Excavation d i <br /> --Domestic/private Drilled Dia. of Well Casing' <br /> Domestic/public Driven Gauge of Casing Z I <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _IZZRotary - Type, of Grout <br /> Disposal Other Other Information <br /> GeophysicZ-a1 1 Surface Seal Installed-- by: <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H, . <br /> PUMP REPLACEMENT: {, [7 State Work Done <br /> PUMP REPAIR: ! O State Work Done <br /> DESTRUCTION OF WELL: ',Well Diameter Approximate Depth 7 <br /> Describe MateHal an2 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 Redulations df the San Joaquin Local j <br /> Health District. Home owner or licensed agent's ' certifies ,the following: <br /> "I certif that in the performance of the wo k for which is permit is issued, I shall , <br /> n employ ny person in such manner as� to be me-s-ubject- o Workman 's Compensation <br /> aws of Cal f rnia. " _ _ <br /> I WIL CALL FO GROUT in <br /> PRIOR TOVGROUTING A FIN L "SPEION,,7 <br /> SIGNED TITLE DATE: �/ .' <br /> R W PLOT PL N ON VERSE DE <br /> - - OR <br /> DEPARTMENj-U9,,KLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY t- DAT — —7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION j <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> q )7 7q �I <br /> EH 1426 Rau_ 17_77 F-4cD -, .-70 e)%A <br />