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��ifi SAN JOAQUIN LOCAL HEALTH DIS_rRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.2944'4-0 <br /> Telephone: (209) 466-678I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued�p �_�g' <br /> This Permit Expire S <br /> x ires I Year From Date Issued <br /> Complete 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 /> ,'oanuin County Crdinance No. 3862 and the Rules and Regulations of the San .Joaquin Local Health <br /> �istr�ct. <br /> EXACT STREET ADDRESS ~- ZR A CJCITY/TOWN <br /> Owner' s Name Phoneb <br /> Address <br /> tv City_ `c�cf7`a Fu <br /> Contractor's Name License# _M le/ Phone, 4 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION TNSUFILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN 0 RECONDITION ❑ DESTRUCTIONED <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION ❑ PUMP REPAIR 9�— PUMP REPLACEMENT ❑ <br /> b <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP — <br /> SALFIELD 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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> A_ irrigation 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 �q L <br /> Type of Pump <br /> SUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑State Work Done—R-,, <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 A <br /> laws of California. " •� <br /> I WILL CA L FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED _ TITLE: DATE: <br /> DR W PLOT PL N ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY� A1114 DATE INSPECTION BY s DATE <br /> EH 1426 Rev. 12-77 ___ 1 /78 2M <br />