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�- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F FFICE USE: 1601 E. Hazelton Ave. ; Stockton, CA 95205 Permit No. <br /> Telephone: (209) 46'6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> This Permit Expires I Year From Date .Issued <br /> Complete In Triplicate _3d C. <br /> Ap lication is hereby made to the San Joaquin Local Health District for a � o construct <br /> p y � p � <br /> and/or install the work herein described.' This application is made,in compliance with San <br /> oaquin County Ordinance No. 1862 and the Rules and Regulations of the. San, Joaquin Local Health <br /> District. <br /> �ACTSTREET ADDRESS CITY/TOWNS�� <br /> Owner -s—Name Phone 1 <br /> Address M4 � I <br /> . city <br /> Contractor' s Name -F- S License# Phone 3t_,!R_3.3,5 • _ <br /> i <br /> TS CERTIrTCATE OF WORKMAN'S COMPENSATIO�d INSURANCE ON FILE WITH SJLHD? YES 1110 <br /> 4 <br /> TYPE OF WORK (Check) : NEW WELD$ DEEPEN Cf RECONDITION Q DESTRUCTION d <br /> WELL CHLORINATION D WELL ABANDONMENT 0 OTHER 0 <br /> �.. ,.x PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST:. SEPTIC TANKffiD ` SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /e)[� CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL7aD � PUBLIC DOMESTIC .WELL <br /> JNTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation_L-), ' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven < Gauge of Casing / ---- -- - - - <br /> Irrigation Gravel Pack Depth of Grout Seal _ ` <br /> E Cathodic Protection Rotary , "Type of Grout Ifo <br /> Disposal Other Other Information <br /> Geophysical Surface Sea] Installed by;U 6nA <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump H.P. <br /> -PTJMP REPLACEMENT: (] State Work- Done - <br /> PUMP REPAIR: Q State Work' Done <br /> DESTRUCTION OF-WELL: ' - Wel•1--D-fdmeter Approximate Depth ' <br /> Describe-Materia and Procedure <br /> 1. hereby certify that I have prepared this-..application and that the work will be done in accordancf <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 fo'r_-.which this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> f laws of California." <br />[ I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING ANDA FINAL INSPECTION. ` I <br /> SIGNED TITLE: DATE:SIa!1129 <br /> r DR W PLOT L N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />' PHASE I <br />, APPLICATION ACCEPTED BY a,_Z&2nDATE 7 <br /> 7ADDITIONAL COMMENTS: <br /> . .PHASE II GROUT INSPECTION• —I PHASE III -FINAL INSPECTIO <br />' INSPECTION BY ., DATE INSPECTION BY DATE <br /> EH 1426 Rev. 12-77 1 /78 2M <br />