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r- SAN JOAQUIN .LOCAL ,HEALI-H DIS ERIC I <br /> FOR OFFICE US-E: 1601 E. Hazelton' Ave. , Stockton, CA 95205 Permit No. <br /> =' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued_o <br /> ThiS. Permit Expires 1 Year From Date' Issued <br /> Complete In Trip icate <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 /> 4oaquin County Ordinance No. 1862 and the Rules and Regulations of the. San Joaquin Local - Health <br /> r'. Strict. lyT-f — O <br /> EXACT STREET' AD 0-RESS S CITY/TOWN' c <br /> Owner's Name. Qu Phone, <br /> Address ocL , City n <br /> Contractor' s Name License#3 O9 Phonef:3 (e!1-3a1 . <br /> TS CERTIFICATE OF WORKIIAN'S C0111PENSATI0"a I'NSURAINCE ON FILE WITH SJLHD? YES i. NO <br /> TYPE- 01= WORK (Check) : -NEW WELL DEEPEN ❑ REjCONDITION [ DESTRUCTION ED <br /> WELL CHLORINATION 0 WELL ;ABANDONM_ENT p OTHER (-3 <br /> i <br /> PUMP INSTALLATION CK PUMP �REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC -TANK Le- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD rCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBL NC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL d� CONSTRUCTION SPECIFICATIONS• <br /> Industrial Cable Tool Y*�` Dia. of Well Excavation. <br /> L Domestic/private Dri 11 ed !` .� ' ^<Di-a. ;of Wel 1 Casing )`'', <br /> IE <br /> Domestic/public ► Driven Gauge 'of Casing la ' <br /> Irrigation ' Gravel Pack Depth :of Grout Seal <br /> Cathodic Protecti an Rotary Type of Grout�°p ,_,V. w <br /> Disposal Other Other ,Information <br /> Geophysical Surface Seal Installed; b <br /> PUMP INSTALLATION: Contractor S <br /> ;,Type of Pump. H.P. 3 <br /> PUMP REPLACEMENT: :Q State Work Done' <br /> PUMP REPAIR: Q State Wo Done f <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 in' accordanc <br /> ' with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Homeowner 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 CAL FOR A GROUT INSPECTION-PRIOR TO .GROUT_I.NG._AND.. A...FINAL INSPECTION. <br /> SIGNED --•TITLE;., ,I DATE: <br /> (DRAW PL PLAN ON REVERS SDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE $ <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPE=CTION BY ATE !� <br /> 6 <br /> EH 1426 Rev. 12=77 ., 1%78 2M. <br />