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SAN JOAQUIN LOCAL HEAITH DISTRICT <br /> FOR OFFICE USE: 60i E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> Telephone: (209) 466-6781 <br /> I I #I- Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires 1 Year From Date Issued <br /> Coniplete 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 /> loan,:in County Ordinance ':u. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS / 1��1/�c� tr `c� _ CITY/TOWN <br /> /CGL, .c>; Phone <br /> Owner's Name / , �- /�C��'-Pil.-���^ .__. <br /> Address �����1 City <br /> Contractor's Name License# _ Phone <br /> IS CERTIFICATE OF WORKMAN'S CO'1PEi+SATIT! INSURA"ICE ON FILE WITH SJLHD? YES NO i <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK J� /-71 SEWER LINES PIT PRIVY <br /> 112- <br /> t SEWAGE DISPOSAL FIELD CESSPGOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 1.1. <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_ <br /> Irrigation Gravel Pack Depth of Grout Sea C <br /> _ Cathodic Protection Rotary Type of Grout <br /> __Disposal Other_ Other Information <br /> _Geophysical _ Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor ,Q <br /> Type of Pump H.P. 2 0 <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <br /> 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 /> 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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. p <br /> SIGNED <br /> TITLE: DATE: —7U <br /> DR W PLT L N ON REVERSE SIDE <br /> F R DEP .RTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> PPLIC TION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III , INAL SPECTION <br /> xINSPECTION BY DATE INSPECT,ON B�',"� ATV 7/1 <br /> EH 1426 Rev. 12-77 1/78 1�qM <br />