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r SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.,9 Y7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -�-'7 <br /> This Permit Ex ices' 1 Year Fror>1 Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct ' <br /> dod/or install the work herein described. This, application -,is made in compliance with San <br /> Joaquin County Ordinance,,-No. 1862 and the Rules and Regulat.ions. of the San Joaquin- Local Health. � t <br /> r',istrict. <br /> E <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name Phone =109.: <br /> Address 5",< P City <br /> Contractor`s Name 4„ J, ''"Y�, '" - _ _ Li cense nro3 Phone3� 4292( <br /> IS CFRTIFICATE OF WORKMAN'S C011P£NSATIO111 I'1SL'RANCE ON FILE WITH SJLHD? YES NO <br /> TYPE of WORK (Check) : NEW WEL : 7 DEEPEN ❑ RECONDITION ® DESTRUCTION d <br /> WELL CHLLR NATION WELL ABANDONMENT 0 OTHERF-J <br /> P,,U;P, INSTALLATION PUMP REPAIR PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SE fic,TANK SEWER LINES PIT PRIVY @ <br /> SEWAGE `DISP-OSAL--FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN E -` iPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF -WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ;` Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 1-0 <br /> Irrigatfonw­=� :. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ..' `Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: 3 <br /> PUMP INSTALLATION: Contractor <br /> 4 Type of Pump ' H.P.4 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Q State Work Done r <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 i�n 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: 7.\' 11 <br /> "I certify that in the performance of the work for which this permit is issued, I 'sha11 ! <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, A GROUT YqSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />• SIGNED TITLE: DATE:3`-_tZ—? <br /> (DRAW PLT PLAN ON REVERSE SIDE <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> I <br /> APPLICATION ACCEPTED BY DATE3 <br /> ADDITIONAL COMMENTS: 9 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> i <br /> 1. <br />-F-H. 1426 Rev. 12-77 . _ - -- - -- T/78 -- 2M <br />