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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: ✓ 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> E <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued�� <br /> p This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Applica o 's hereby made to the San Joaquin Local Health District for a permit to construct- <br /> and/or instal he work herein described. This application is made in -compliance with San <br /> Joaquin County dinance No.- 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. '' } <br /> EXACT SIRE ADDRE We5� �.An1 Q, I-,rrOV\J—r4Gp CITY/TOWN <br /> Owner's Name Phone2:s'°- s Z.3 -- <br /> Address Gov �_ z- City /6,�-; e tx,- Pte, <br /> Contractor' s Name - License# 7fG11 Phone <br /> IS CERTIFICATE OF WORKMAN'S CO"tPENSA IO. IPlS(1RA"ICE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL. k DEEPEN El_ RECONDITION Cj DESTRUCTION❑ .� <br /> WELL CHLORINATION C3 WELL ABANDONMENT Q OTHER 0 v <br /> PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES` .r+ PIT PRIVY . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMEST ff WEAL 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 i <br /> Geophysical Surface Seal Installed by: .- .� - <br /> PUMP INSTALLATION: Contractor t� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: liflState Work Done <br /> PUMP REPAIR: ::Q State Work Done + <br /> DESTRUCTION OF WELL:,; -Well Diameter Approximate Depth <br /> De'scri be Material an2 Procedure <br /> I hereby certify that I.'have prepared."th i s ap.p1 J cati on..and that .the work wi l l_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 s n in such manner as to become subject to Workman's Compensation <br /> laws of Cal ' orni <br /> I WILL CALL UT,, I ECTION PRIOR TO GROUTING AND MFINAL INSPECTION. <br /> SIGNED TITLE: 2,eDATE: <br /> (DRAW PLT PLAN ON REV RSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i 9 <br /> APPLIC ION EPT£D 8Y. DATE <br /> ADDITIONAL COMMENTS: <br /> j PHA II ROUT INSPECTION PHASE II'[ FINAL INSPECTION <br /> INSPECTION BY DATE /p 26 y INSPECTION BY DATE Lb-31-1 <br />' dep=kti o+G <br /> t EH 1426 Rdv. 12-77 1/78 2M <br />