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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: V 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. _ l{ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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 appl.ication: is made in compliance with' San f <br /> Joaquin County Ordinance No'.' 1862 -and the Rules and Regulations of the San Joaquin Local Health I <br /> District. f GI. <br /> EXACT STREET ADDRESS / �® , CITY/TOWN 5 C� <br /> Owner's Name l//2 Phone <br /> Addres's "7} 5, 1 City <br /> Contractor' s NameTIJSa icense# f: 7Z Phone � z �� f <br /> � "- 4 '. �.. .1, ♦P 1 -,h�4r - _ .-.m�--...rte.— :- ..a .;.:. '� <br /> I5 CERTIFICATE 4F_WORKt:1,4PJ'S GO"1PENSATIOM yINSUR'A^10E ON FILE WITH SJLHD? YES 0- <br /> TYPE OFWORK. (Check) : NEW WELL CI' -;,DEEPEN 0 . .RECONDITION [D DESTRUCTION['J. � <br /> WELL CHLORINATION 0 ,—WELL ABANDONMENT 0 _ -OTHER Q <br /> PUMP INSTALLATION 2q " -PUMP REPAIR CI PUMP REPLACEMENT EJ <br /> DISTANCE TO NEAREST: SEPTIC TANK F ,-SEWER LINES ` PIT PRIVY <br /> SEWAGE DISPOSAL�'FIELD CESSP OL/SEEPAGE'-PIT* OTHER c4 <br /> PROPERTY LIN.E,'- PRIVATE DO ESTI-Ca. WELL. PUBLIC DOMESTIC WELL <br /> -i'-"I'NtENDED USE "" ; TYPE OF WELL. I <br /> Industrial CONSTRUCT.ION ,SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation,._.__ <br /> Domestic/private Drilled "�--D&.- of Well <br /> , Casing Driven Gauge <br /> ; <br /> of Casing � <br /> Irrigation Gravel Pack Depth of Grout-Sea ­ <br /> Cathodic Protection Rotary Type of Grout <br /> .Disposal Other Other Information <br /> Geophysical Surface Seal Insta 7ed <br /> PUMP INSTALLATION: Contractor <br /> t <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> ;DESTRUCTIONLOF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby certify that I have prepared this application and that the work will be done in accordancI <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. <br /> SIGNED <br /> TITLE: DATE: <br /> _.ii D W PL T PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOOR DEP RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY s DATE` 5--��, <br /> ADDITIONAL COMMENTS: o <br /> PHASE II GROUT INSPECTION PHASE III ' AL INSPECTION, <br /> INSPECTION 8Y DATE � INSPECTION BY ATE _EH 14 26 Rev. 9/78 ' <br /> - c_ /78 - 2M <br />