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SAN JOAQUINTLOCAL HEALTH DISTRICT <br /> FQR Fr ICESE: 1601 E. HazeltaK'hve':, Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued—,2J? <br /> This Permit Ex fres 1 -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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin .Local Health <br /> District. � <br /> EXACT STREET ADDRESS — Go D` 'CITY/TOWN <br /> Owner' s Name J0,11 Phone <br /> Address C` City. <br /> Contractor's Name d r License# Phone IG"Ifr <br /> IS CERTIFICATE OF WORKMAN' COMPENSATTM INS RANCE ON PfILE WITH SJLHD? YES NO . <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER r1 � <br /> PUMP INSTALLATION, CQ PUMP REPAIR❑ PUMP REPLACEMENT El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP SRL FIELD CESSPOOL/SEEPAGE PIT OTHER U/EZl_-C75 <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 &3a&J <br /> Irrigation )!L Gravel Pack Depth of Grout Seal <br /> Cathodic Protection k-- 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 <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 WILL CALL FOR A GRO INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> r SIGNED T'ITLE: DATE: <br /> DR W PLOT PLM ON REVERSE SIDE <br /> FOR DEPA TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE I-3--75? <br /> ADDITIONAL COMMENTS : <br /> PHIIIE II GROUT INSIPECTION PHASE JII FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> LlS,I <br /> 7 /7R 4 <br />