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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.Zg_ /a g6 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued sf-as�8 <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> oplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ­id/or install the work herein described. This application is made in compliance with San <br /> )anuin County Ordinance 1:o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> ' str^ct. <br /> ;ACT STREET ADDRESS la 1 7 2 y_ +1� CITY/TOWN Q <br /> -ner' s Name a Phone < < <br /> +dress ey City <br /> ntractor' s Name License2YYfts Phoned Y4//, ? <br /> CERTIFICATE OF WORKItAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES e--�"40 <br /> YPE OF WORK (Check) : NEW WELL[j-DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT O OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> ISTANCE TO NEAREST: SEPTIC TANK "4! -SEWER LINES 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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> gestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 5—V <br /> Cathodic Protection 6 R ary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: aL <br /> 'JMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> !MP REPLACEMENT: ❑State Work Done <br /> IMP REPAIR: ❑State Work Done <br /> STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordar <br /> ith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <br /> ealth 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 /> WILL CALL FOR A GROUT INSPECTION PRIOR T GROUTING AND A FINAL INSPECTION. <br /> :IGNED — TITLE: DATE: , 7 S; <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> FORD ARTME T USE ONLY <br /> �NASE I <br /> APPLICATION ACCEPTED BY n 1 "A DATE <br /> •DDITIONAL COMMENTS : 0 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ISPECTION BY DATE INSPECTION BYT!.--, ' DATE <br /> "d9F Rav 19_77 1 /78 2'" <br />