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"W4 (g !46 ��� 'r , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR F CE USE: 1601 E. Hazelton Ave. , Stockton, CA - 95205 Permit No. 99 //J 3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT. Date Issuedg-1_� <br /> This Permit Expires 1 Year From 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. t <br /> EXACT STREET ADDRESS /3 O / ..lc���_ � _ CITY/TOWN <br /> Owner's Name L/ Phone <br /> Address � .' G // � '�, . . e � - - City <br /> Contractor' s Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION TINSURAINCE ON FILE WITH SJLHD? YES ,, NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ® DESTRUCTION[ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT p OTHER 0 , <br /> PUMP INSTALLATION [3 PUMP REPAIR M PUMP REPLACEMENT Q <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 /> C _Domestic/private Drilled Dia. of Well Casing c� <br /> Domesti-cypubl i c T` --Dri-veri - ... `­- - Gauge of-Cas i rig <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type e of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor cSJ <br /> Type of Pump ! M.P. <br /> PUMP REPLACEMENT: : E]State Work Done <br /> PUMP REPAIR: MState Work Done <br /> DESTRUCTION OF WELL: Well Diameter U Approximate Depth ' <br /> Describe Material and Procedure <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 /> 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 person in such manner as to become subject to Workman's Compensation <br /> laws of California." z <br /> I WILL CALL FOR A GROUT IN -ECT- N /PRT-QR TO GROUTING. AND A FINAL INSPECTION. <br /> SIGNED rt _ f _ TITLE: DATE: <br /> D A ;.PLOT P N ON REVERSE SIDE)__ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - i�-_ DATE <br /> ADDITIONAL COMMENTS : <br /> 2 r Ap <br /> PHASE II GROUT INSPECTION PHASElil FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />