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l l o SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR F ICE USE: 1601 E'. Hazelton Ave. ;=Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP 'PERMIT Date Issued &-_1-2e. <br /> This Permit Expires 1 Year From Date Issued' <br /> Complete In Triplicate , <br /> Application is hereby made to the San Joaquin- Local Healrth . District.-for a permit to construct t <br /> and/or install the work herein described. This application is made in compliance with San I <br /> Joaquin County Ordinance No. 1862 and the Rules-and Regulations of the San Joaquin Local' Health <br /> District. <br /> 'EXACT STREET -ADDRESS_ IL <br /> ss� " ,:, . �� �a�;� - : -- --CITY/TQWN /crZ <br /> Owner' s Name nSer diA Phone <br /> Address .!644 �, ie�a� City <br /> Contractor's Names u. License# /1.t 7�1,1 Phone� 7,4 <br /> IS CERTIFICATE OF WORKMAN'S COi"P ATIO-N INSURANCE ON FILE WITH SJLHD? YES X NO iM <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT.0 s <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 /> x Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> r Cathodic Protection Rotary Type of Grout F <br /> Disposal Other Other Information <br /> t Geophysical Surface Seal Installed-by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP .REPLACEMENT:. PflState Work Bone 1AA40 _ <br />! PUMP REPAIR: ❑State Work Done f, <br />�. - __ <br /> DESTRUCTION -O,FYWELL:�"' WeTI"D7 am`etertl ` �� �� � Appraxima`te Depth � <br /> Describe Material and Procedure <br /> I'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 /> k not employ any person in such manner as to become -subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CAL FOR A GROUT INSP .CTIONAP,,RtM TO. GROUTING AND A FINAL INSPECTION. <br /> S IGNE ,l � ITITLE: DATE: r l <br /> OR OT PLVAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �&J <br /> APPLICATION ACCEPTED BY f, I DATE / 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II T INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY � DATE <br /> L EH 1426 Rev: �12-77 ' - - - /78 2M .,-, <br />