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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave.. , Stockton, CA 95205 Permit No. — S <br /> Telephone: (209) 466-67811 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ 4 <br /> This Permit Expires 1 Year From Date Issued 1 <br /> Complete I.n Triplicate <br /> Application is hereby made tolthe San .Joaquin Local, Health District for a permit to construct <br /> and/or install the work hereinidescribed. This application is made in compliance with San <br />,'oaquin County Ordinance 1Yo, ' 1$62 and the Rules and Regulations of the San Joaquin Local 'Health <br /> District. <br /> EXACT- ,STREET ADDRESS !t /� Lam' — CITY/TOWN <br /> Owner's Name : Phone <br /> Address City ; <br /> Contractor's Name <br /> License Phone __ _ <br /> /_ <br /> IS CERTIFICATE OF WORKHAN',S COMPENSATION -111SURAI'•fCE ON FILE'43TFI SJLHD?'r' YES NO <br /> TYPE OF WORK (Check) : NEW WELL Pa— DEEPEN ❑ RECONDITION DESTRUCTION[ <br /> WELL CHLORINATION 0 WELL,ASANDONMENT p OTHER 0 <br /> PUMP INSTALLATION W YJ ' PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: ''SQTI,C TANK,/,5--O SEWER LI—NES/:—S--6 PIT PRIVY <br /> rSEWAGE DIS 05 L FIELD CEOL/SEEPAGE PIT OTHER <br /> -PROP•ERTY .LINIr PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> k � . <br /> INTENDED USE TYP .�OF-WELL'S CONSTRUCTION SPECIFICATIONS <br /> Industrial - ;� Cable—ToolI- lDia ~of,'We11Ecavation L7 <br /> Domestic/private DrilledDia. of Well Casing <br /> Domestic/public 'DrivenGapge'of Casing / <br /> Irrigation _ Gravel - Pack'. , De 6f of Grout <br /> Cathodic Protection X x ,Rot'ary.M I� Type of, Grout <br /> Disposal Other` Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor H.P <br /> Type of Pump _ - -- <br /> PUMP REPLACEMENT— [J Stade Work Done y <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4 I ` <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 /> 6Health 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." 1. - <br />' I WILL CALL FOR GROUT INSPECTION`PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED o�.�� Y ' TI-TLE-: DATE: <br /> D W PL PL N •ON. REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY x �� <br /> PHASE I '`I � <br />`APPLICATION ACCEPTED BY ' - . t DATE6 Z7_�_ <br />!ADDITIONAL COMMENTS: r - <br /> 4 z - -47 <br /> PHASE II GROUT INSPECTION ; PHASE II1- FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY . �`:_ DATE <br /> .ru: innc n ... I7 -77 -- 1_/78 2M,- <br />