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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205Permit No. <br /> Telephone: (209) 466-6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <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 . ,01 f1__F . CITY/TOWN a <br /> Owner's Name tj lJAI i Phone / <br /> Address - � ` <br /> . ��.�. 4YPR ",e-. _ City <br /> Contractor' s Name C,C ' <br /> - r ole ee. e_License# GG©z Phone o�14z-Sslg7 <br /> IS CERTIFICATE OF WOR0AN'S COIMPENSATIO'! TNSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL I$�' DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK_50 SEWER LINES X5-0 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 r <br /> Industrial Cable Tool Dia: of Well Excavation Q <br /> =Domesti c/•pri vate Dri 11 ed Y `Dia`:of`WdI 1 Cas i ng ym - <br /> Domestic/public Driven Gauge, of Casing <br /> Irrigation Gravel Pack Depth' of'Graut 'Sea � 0 <br /> Cathodic Protection _Rotary Type,of Grout N TC % <br /> Disposal; Other t Other`, Information <br /> Geophysical ' J. }. .Surface Seal Installed 57.7 <br /> PUMP INSTALLATION: Contractor_. Ze wE <br /> � <br /> Type oflump H.P. <br /> PUMP REPLACEMENT: Q State. Work `'Done -- _.-_ — <br /> PUMP REPAIR: ` <br /> QState Rork-Done" <br />' DESTRUCTION OF WELL: Well Diameter x.`' Approximate Depth <br /> Describe Material and Procedure <br /> 'I hereby cert'i fy ',that it 'have prepared this ,application and that t�6 work will be done in accordance} <br /> with San Joaquin. County Ordinances , State Laws , and Rules and, Regulafti:ons__of .the-.Sa_n- Joaquin.�Loca7 <br /> Health District. Nome owner or licensed agent's signature`�certifies the following: <br /> "I certi-fy--that-- i-n -the-performance of the ,work for which-thi.s_per-mi-t::.i.s_i-s.suedi, I shall q <br /> not employ any person in such manner as to'_become subject +to Workman's Com ensation <br /> laws of Calif ia." p <br /> I WILL CALL -OR AGR UTI £CTION PRIOR, TO GROUTIA6 ANDn FINAL INSPECTION. <br /> SIGNED____)VjZ(/UAVV <br /> •- - - TITLE:-ANA DATE: <br /> (DRAW PLT PLAN, ON REVERE SIDE)- <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: ' <br /> yPHAS.E_ .LI-_GROUT-..INSP.ECT.ION <br /> F_fNAL_' INSPECTION. I <br />'INSPECTION BY i ,� DATE_ -�r�_l� . INSPECTION BY DATE <br />£. 1426 - Rev. 12-77 - . <br />