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SAN JOAQUIN, LOCAL ,HEAL IH UIS I RIL I t <br /> FFICE USE: 1601 E. Hazelton Ave:,, Stockton, CA 95205 Permit No /S L <br /> Telephone: {209) 466-6781 �� <br /> APPLICATION FOR'WELL CONSTRUCTION OR PUMP PERMIT Date i'issued//i— 7 y <br /> This Permit Ex i res 1` Year' From ,Date Isscied <br /> Complete Irl ca <br /> Triplite <br /> Application is hereby made to the San Joaquin: Local Hea,l'thtDistrict fora permitito construct <br /> and/or install .the work herein described. This a lication is made in compliance with San <br /> Joac�U�n irOUnty Ord Hance <br /> C� pro 1862 and the Rules and. Regulations of the San Joaquin Local Health <br /> EXACT STREET ADDRESS <br /> CITY/TOWN <br /> Owner's Name _ Phone -.1� <br /> Address <br /> C.1 ty .. <br /> Contractor' s Name Y we - License Phone —32/ <br /> 22 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"1 INSURA"I ON FILE WITH SJLHD? YES � fJ0 <br /> TYPE. OFiWORK (Check) : 'NEW WELLE' -DEEPEN ❑ RECONDITION ❑ DESTRUCTION E3 <br /> WELL CHLORINATION ❑� WELL ABANDONMENTxp OTHER❑ <br /> PUMP INSTALLATION ICY PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> `DISTANCE TO NEAREST: SEPTIC TANK /100-tSEWER LINES jq�o SPIT PRIVY <br /> E SEWAGE DISPOSL�FIELD CESSPOOL/SEEPA PIT�S� OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC W LC�l�PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O; <br /> Industrial Cable Tool _.Dia. of _Well.-Excavation <br /> L-- Domestic/private —/--TriIIed, Dia. of Well Casing �� <br /> ~��Domestic ublic f <br /> /P Driven Gauge of Casing Y V <br /> Irrigation :11 Gravel =Pack n Depth of Grout Seal <br /> __^_______Cathodic Protection Rotary Type of Grout 7 <br /> Disposal Other .` - Other- Information <br /> Geophysical . Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor 10611 <br /> tTYPe of Pump < <br /> ( PH,P. i�. <br /> UMP REPLACEMENT: <br /> ❑State Work Done , <br /> JEUMP REPAIR: ❑State Work ne I� <br /> DESTRUCTION OF WELL: Well Diameter x <br /> Approximate Depth <br /> Describe Materia an Proce ure <br />' I hereby certify that I -have prepared this application and that the work will be dione 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 th'e performance of the work for which this permit is issued, I shall <br /> not employ any perso' in such manner 'as to become subject to Workman's Compensation <br /> laws of California, "i. <br /> I WILL CALL FOR A GROUT ;INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> ISIGNED TITLE: DATE:: / <br /> if DRAW PLOT PL N ON REVS 5 SIDE <br />'PHASE I FOR DEPARTMEN USE ONLY <br />'APPLICATION ACCEPTED BY ©ATE / � '7 rADDITIONAL COMMENTS: 11' iM <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY I�. DATE 2 INSPECTION BY C DATE <br /> EH 1426Rev. 12-.77 <br />