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SAN JOAQUIN LOCAL HEALTH UISTRIC1 <br /> FFICE USE: 1601 E. Hazelton Ave.., Stockton, CA 95206 Permit No. i3yS <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued " <br /> This Permit Expires 1 Year From Date Issued , <br /> ;� .. Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or .install the work herein described. This application is made in compliance with San - <br /> Joaquin County Ordinance No. 1862 and the .Rules-and Regulations of the San Joaquin Local Health <br /> District. <br /> S <br /> EXACT�STREr ET'ADDRESS + CITY/TOWN <br /> rr <br /> Owner's Name-412AJ. Phone- j–0,51s, <br /> Address ,Sp 30 , �vJJ/14 _ Ci ty. <br /> Contractor's Name License# Phone .] <br /> IS CERTIFICATE OF WORKMAN`S .COMPENSATMM INSIFA CE ON FILE WITH SJLHD? YES NO <br /> r TYPE OF WORK (Check) : NEW WELLRQ .,. DEEPEN ❑ RECONDITION ❑ DESTRUCTION[j <br /> -WELL CHLORINATION C3 WELL -ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑_ PUMP REPAIR❑ ­PUMP REPLACEMENT Ea <br /> . DISTANCE TO NEAREST: SEPTiC TANK .% SEWERLINES 1+ PIT PRIVY <br /> SEWAGE DISPOSAL� FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LIN?'��WRIVATE DOMESTIC WELLS PUBLIC DOMESTIC WELL _----, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial � Cable Tool Dia. of Well Excavati=on � <br /> Domestic/private Drilled Dia. of Well .Casing a <br /> Domestic/public Driven Gauge of Casing <br /> Irriationl <br /> 9 Gravel Pack Depth of Grout Seal �-- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> { Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ' []State Work Done w� <br /> PUMP REPAIR: ❑State Work Done <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 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 WILLC FORA GROUTASPEdlgfl X11OR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> i R W PLT L N ON REVE SR SIDE <br /> f � FOR EP RTMENT USE ONLY <br /> PHASE I <br />[ ADDITIONAL <br /> ACCEPTED BYG DATE <br /> f ADDITIONAL COMMENTS: OF, <br /> PHASErI.I GROUT INSPECTION t PHASE I FINAL INSPECTION <br /> INSPECTION BY SATE INSPECTION BY DATE -a 7$ <br /> 1426 Rev. 12-77 1/78 2M <br />