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SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 -5 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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. V <br /> EXACT STREET ADDRESS D S� �"¢ ,' o CITY/TOWN cn <br /> Owner`s Name e , A Phone" .S"9�' - 2 �� <br /> Vf <br /> Address e armve City / <br /> Contractor' s Name /)/` ,1 License- Ts.�` Phone S` P <br /> IS CERTIFICATE OF WORK'iAN'S COMIPENSATION INSURANCE ON FILE WITH SJLHD? YES NO y � <br /> TYPE OF WORK (Check)°` NEW WELL❑ DEEPEN ❑ RECONDITION Cl_. �DESTRUCTION❑- `moo <br /> WELL CHLORINATION.❑ _WELL-ABANDONMENT 0— OTHER rJ <br /> PUMP''INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT D D <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY � . <br /> SEWAGE DISPOSAL FIELD CESSPUOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DZMESTIC WELL PUBLIC DOMESTIC WELD <br /> INTENDED USE' ' TYPE OF .WELL., CONSTRUCTION SPECIFICATIONS — <br /> Industriala� Cable Tool Dia. of We 1 Excavation , <br /> Domestic/private Drilled Dia. of Well-.Casing <br /> 1 4-.-- = .Domestic/public-4,T--- T- -: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 b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> f PUMP REPLACEMENT: TO State Work Done fib ' g ems- -e <br /> PUMP .REPAIR: �� ❑State Work Done <br /> DESTRUCTION 'OF WELD.: Well Diameter ,• Approximate Depth <br /> Describe "Materia ant "P�,oce� ure _ _ _ -. <br /> ; 41 <br /> I hereby certify that I 'have prepared this application' and that the work will be done in accordano <br /> ( with Sart Joaquin County Ordinances, State Laws , and Rules.-and Regulations of the San Joaquin Loca' <br /> ' Health District. Home owner or -licensed agent' s -signai:ure certifies the following: s <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. " i <br /> � I WILL CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: r DATEZZ <br /> # DR W PLT L N ON REVERSE SIDE <br /> aF R DEP RTMENT USE ONLY <br /> PHASE I11 <br /> APPLICATION ACCEPTED BY" DATE I <br /> ;ADDITIONAL COMMENTS: <br /> PHASE II GROUT S CTIO PEASE III Z INAL SPECTION <br /> iINSPECTION BY DATE ., �✓, INSPECTION BYTE <br /> 4EH 14 26 Rev. 9/78 " e O� 5 _ /78` 2 <br />