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} SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 2 _ 3G <br /> Telephone (209) 466-6181 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate a <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 /> C Joaquin County Ordinance No.' 1862 and the -Rules and Regulations of the San Joaquin. Local Health <br /> District. ; ' <br /> EXACT STREET ADDRESS [ 1� CITY/TOWN /A AICI <br /> Owner's Name Phone <br /> 4-6 <br /> :.' AddressCi ty S C/ <br /> nse# PhoneContractor's Name N ( , Lice <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATIO" INSURANCEON <br /> FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 800000DEEPEN 0 RECONDITION ❑ DESTRUCTION d 6� <br /> WELL CHLORINATION E3 WELL ABANDONMENT Q OTHER 0 � <br /> PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT C� <br /> k DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES PIT PRIVY <br /> OS <br /> SEWAGE`DIS AL FIELO/O-f' 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 Wel l Excavation /V 371-- � <br /> Domestic/private Drilled Dia. of Well Casing 5"/ <br /> j t)omestic/public *' Driven Gauge of Casing ' CL 4 B <br /> Irrigation Gr Pack Depth. of Grout Seal 'M CLrt1 <br /> Cathodic Protection; ►_ otary Type of Grout <br /> Disposal Other ', Other Information <br /> Geophysical Surface Seal Instal ed b <br /> r PUMP INS A LATI.ON: Contractor <br /> Typeof Pump _ H.P. <br /> I PUMP REPLACEMENT: Q State Work Done <br /> PUMP'-REPAIR: QState Work Done <br /> k <br /> DESTRUCTION OF WELL: WelliDiameter ,.-- Approximate Depth <br /> Describe Mater5l and Procedure <br /> t I hereby certify that I have prepared this application and that the work will be done in accordan� <br /> with San Joaquin County Ordinances , State Laws,—d nd Rules and Regulations of the San Joaquin Loca' <br /> Health District. Home own6i 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 emp y any person in such manner as to become subject to Workman's Compensation <br /> laws o alifornia." <br /> I WILL CA FOR GROUT PECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE DATE: ' <br /> ' <br /> (DRAW PLOT L N _ON REVERSE SIDE <br /> k <br /> f FOR DEP RTMENT USE ONLY <br /> L <br /> f PHASE I . <br /> �//p <br /> C APPLICATION ACCEPTED BY .-. DATE <br /> ADDITIONAL COMMENTS: "t <br /> PHASE II GROUTi INSPECTION . vPHASE III FINAL INSPECTION <br /> INSPECTION BY : DATE INSPECTION BY DATE <br /> 7 8 ° 2M <br /> FH 1426 RPv_ 12-77 " <br />