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an f SAN JOAQUIN LOCAL HEALTH DISIRICI <br /> 71 <br /> F ICE USE: 1601 E. Hazelton•Ave. , Stockton, CA 95205 Permit No. 3 <br /> Telephone: (209) -466•-6781 G <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> APP lication 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 /> 'oaQuin County Ordinance' No. (i1862 and the Rules and Regulations. of the San Joaquin .Local Health <br />( District. i <br /> EXACT STREET AD6RESSCITY/TOWN <br /> Owner' s Name l T Phone <br /> Address City <br /> Contractor' s Name k2'—�cl Li cense# /y3724—Phone -�— <br /> IS CERTIFICATE OF WORKMAN'S C0MP%fftATTn,11J INS1JRA1,-dCE--0N FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLM DEEPEN C3 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER0 - <br /> PUMP INSTALLATION El PUMP REPAIRCRI PUMP REPLACEMENT EJ \ <br /> 4 <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 /> f Cathodic Protection Rotary Type of Grout <br /> Disposal ( Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type `:6f Pump <br /> PUMP- REPLACEMENT: []State Work Done <br /> PUMP REPAIR: (State Work Donekt <br /> -. DESTRUCTION OF WELL: Well '',Diameter Approximate Depth <br /> i Describe Material and Procedure <br /> ` I hereby certify that I havd prepared this application and that the work will be- done in accordanc <br /> ,with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owneor 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'Isuch manner as to become subject to Workman's Compensation <br /> laws of California. " I. <br /> I WILL CALL FOR ,A GROUT INSP N P TO GROUTING AND A F.INAL' INSPECTION. <br /> ITLE: DATE: <br /> : SIGNED l RA LOT PL ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �%(/ DATE -z <br /> (ADDITIONAL COMMENTS: :! • <br /> f PHASE II GROUT .INSPECTION PHASE III FINAL INSPECTION <br /> "INSPECTION BY DATE INSPECTION BY DATEPL <br /> - -� <br /> r[1 1 All-1 n_.. 1'9 V 77 �.. - .1/78 <br />