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FFICE USE: AN JOAQUIN LOCAL :HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. /l <br /> Telephone: (209) 466-6781 r� <br /> APPLICATION FOR WELL CONSTRUCTION OR PIMP PERMIT Date Issued <br /> `3~3a'7r <br /> This Permit F'x ires 1. Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District..for a permit <br /> and/or install the work herein described, . This application is made .in- complianceto construct .. <br /> Diu;►, County Ordinance .rYo. 1862 a ith <br /> ' Ji striC� nd the Rules :and Regulat ions of•the SanJoaquinwLocalaHealth <br /> St , <br /> i <br /> ' EXACT STREET 'ADDRESS /! 2 a 7 <br /> Owner's Name CITY/TOWN <br /> Address.. Phone_ . Q � r- • <br /> City <br /> Contractor's Name y„ c�,�' <br /> License# Phone <br /> IS CERTIFICATE OF WORKMAN'S GOMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN ❑ RECONDITION NO <br /> WELL CHLORINATION D WELL ABANDONMENT p DESTRUCTION[:] <br /> 0 N <br /> PUMP INSTALLATION F4 PUMP REPAIRE] PUMP REPLACEMENT Lj, <br /> k <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE .PIT OTHER ` <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ` <br /> INTENDED USE ( TYPE OF WELL <br /> Industrial ' Cable Tool Dia. of WCOiSTRUaTIONoSPECIFICATIONS <br /> Domestic/private <br />—Domestic/public Drilled Dia. of Well Casing <br /> Irrigation Driven Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection t Rotary T <br /> Disposal I Other tof Grout <br /> Geophysical Othhe er Information � <br /> Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: O Sta g Work Done <br /> 7ESTRUCTION OF WELL: Well Diameter . ! <br /> Describe Materia an Procedure Approximate Depth <br /> I ' <br />[ hereby certify that I have prepared this application and that the work will be done in accordance <br /> lith San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Local • <br /> lealth District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that in the performance of the work for which this <br /> permit s issue , I <br /> not employ any person in such manner as to become subject to Workman�s Compensational ] C <br /> laws of Califo . It <br /> WILL CA ROUT INSP ION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED TITLE: <br /> DR W. PLOT PL. N ON REVERSE SIDE Pi�� DATE: �3 79 <br /> tiASE I FOR D PARTMENT USE ONLY <br /> pPLICATION ACCEPTED BY <br />)DITIONAL COMMENTS: --- DATE-43 ;111-79 <br /> PHASE II GROUT INSPECTION <br /> ISPECTION BY DATE PHASE II . I INSPECTION <br /> - INSPECTION BY DATE 2 78 <br /> t <br /> 1426°:. Rev. 12-77 <br /> x <br />