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SAN JOAQUI� L..00A.L,.HEALTH .DISTRICT <br /> EQ FFICE USE: 1601 E. Hazelton`Ave. , Stockton, CA 95205 Permit No. d <br /> Telephone:. (209) 466-6781 <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ices I Year From ,Date Issued ! <br /> Compete In Triplicate <br /> ! Application is hereby made to the San Joaquin Local Health Distr-ict for a p rmit to construct <br /> and/or install the work herein described. This application is made in comp lianceirwith an <br /> Joaquin County Ordinance ado. :1862 and the Rules and Regulations of the San Joaquin ,Local ,,Health <br /> f District. <br /> EXACT STREET ADDRESS 3 <br /> CITY/TOWN�S �T� <br /> Owner' s Name PAI r Phone , <br /> y <br /> Address C i ty, <br /> -- <br /> ' Contractor' s Namem.60SF cge& Azr Li cense d. Phone ?-� <br /> IS CERTIFICATE OFWORK"IAN'S CO"IPE"JSATIO"I-'INO A"fCE ON FILE WITH ,SJLHD? YES NO <br /> STYPE OF WORK (Check) : _NEW WELL Q— DEEPEN 0 , RECONDITION j] DESTRUCTION En <br /> WELL CHLORINATION C3 WELL ABANDONMENT ICI OTHER El <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT EJ G <br /> DISTANCE TO NEAREST: SEPTICITANK�-tSEWER LINES�!PIT PRIVY -[ <br /> SEWAGE DISPOSAL FIELD /OVtCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY.' LINE(a.LPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE .TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 4 Industrial Cable Tool Dia. of Well Excavation i Q': flA," <br /> /1Domestic/private Drilled Dia. of Well Casing - ' t <br /> }Domestic/public Driven Gauge of Casing �c., 1-612 <br /> -Irrigation Gravel: Pack Depth of Grout Seal <br /> i "Cathodic Protection __Rotary' Type of !Grout <br /> E Disposal Other, Other Information iM <br /> ' Geophysical ; Surface Seal installed b <br /> PUMP INSTALLATION: Contractor <br /> k 'Type of Pump H.P. it <br /> PUMP REPLACEMENT: Fl State Work Done°` <br /> PUMP REPAIR:REPAIR: - []State Work Done_ ` 1 <br /> DESTRUCTION OF WELL-: iWell Diameter- Approximate Depth <br /> Describe Materia an Procedure =JE <br /> I hereby certify that I have, prepared this application and that the work will be,,done in accordant <br /> Ewith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the 6 an Joaquin Loca' <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." r <br /> I WILL CALL FORA-GROUT INSPECTION PRIOR TO GROUTING AND Z FINAL INSPECTION. <br /> SIGNED -� TITLE: DATE: �o / 7 <br /> (DRAW PLOT_P. NON REVERSE SIDE �i <br /> FOR DEPARTMENT--USE' ONLY <br /> 11 PHASE I Y <br /> DATE <br /> APPLICA N ACCEPTED BY <br /> ADD IT , NQL OMMENTS: <br /> f PHASE II GROUT INSPECTION PHASE-111- FINAL INSPECTION - <br /> INSPECTION <br /> NSPECTION -INSPECTION BY DATE INSPECTION <br /> im <br /> �� _ 1178 <br /> ,EH 1426 Rev. 12-77 - - _ <br />