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c'orn /4 � SAN. J'OAQUIN- LOCAL.,HEALTH DIS-fRICT <br /> QR F ICE USE: 1601 E. Hazelton Ave, ; Stockton, CA 95205 Permit No. <br /> Y 7 Telephone:. (209)' 466-6781 <br /> j (APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued S: <br /> a1 This Permit`Ex ires- 1 Year kFrom.-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_N ,,, ,,, ��I�„ Cry vts+ �� CITY/TOWN <br /> IOwner's Name �� �L,.„v`� �d Phone� - <br /> Address Se 3 a Al. 14-0«—�. (CZ m� City <br /> Contractor' s Name ted/ d - License#` 3_?°��Phone <br /> il <br /> IS CERTIFICATE OF WORKMAN'S QPENSATIO'1 INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN [] PRECONDITION ❑ DESTRUCTIONQ <br /> WELL CHLORINATION Q WELL ABANDONMENT p OTHER ❑ ' <br /> PUMP INSTALLATION E3 . PUMP REPAIR® PUMP REPLACEMENT [] <br /> S <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 /> _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 <br /> Type of Pump ,6 ire H.P. ls` <br /> PUMP REPLACEMENT: Q State Work Done <br />` PUMP REPAIR: G State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Materia and-Procedure <br /> I hereby certify that I1have prepared this application and that the work will be done in accordance <br /> with San Joaquin CountylOrdinances, State Laws , and Rules and Regulations of the San Joaquin Local ' <br />' Health District. Homeowner 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 /> k .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-IIINSPEC N NIQRTO GROUTING AND A FINAL INSPECTION. <br /> S I G N E D � <br /> (TLE: DATE: <br /> R W LOT PL ON REVERS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I b. <br /> APPLICATION ACCEPTED BY- DATE v)' <br /> ADDITIONAL COMMENTS: 11 <br /> PHASE II GROUT INSPECTION PHA$E.Aik FINAL INSPECTION <br /> INSPECTION BY_ �4„_ _ DATE INSPECTION BY-U DATEa� . <br /> EH 1426 Rev. 12-77- <br /> �I: .• :.,, ,... . f>, - -��T /78 2M <br />