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�.. i <br /> SAN JOAQUIN;.LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Haielton Ave. , Stockton, CA 95205 Permit No.7g ,_�s <br /> Telephone: - (209) .466.,-6781 <br />--+° Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires 1 Year From Date . Issued . <br /> . <br /> (Complete <br /> In Tri l.icate <br /> _ <br /> Application is hereby made to the San Joaquin Local Health 'Distr.ict 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. 0 . <br /> EXACT. STREET ADDRESS �. - CITYFOWN� <br /> Owner's Name [� Phone <br /> Address <br /> -City <br /> Contractor' s Name <br /> License#, f `r Phone <br /> IS CERTIFICATE OF ld .Kr1Ard's CO"ZPENSATIO"1 INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION Q DESTRUCTION C3 <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK & SEWER LINES IT PRIVY v <br /> SEWAGE_.D.I.SPOSAL-�-FI-Ef�D --- CE S-PO LJSEEPAGE•-P-IT DTH"ER�" <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL_ PUBL C DOMESTIC WELL <br /> _ S.e. <br /> INTENDED USE TYPE OF WELL �CONSTRUCTION'SPECIFI-CATIONS <br /> Industrial �C-ab1e �Too1' - -Dia. of' Wel�l Excavation:.," °�' <br /> ��.. <br /> �WDomestic/private Drilled ' Dia. of Well Casing <br /> Domestic/public Driven ' `' ,,.� Gauge of Casing f � r <br /> Irrigation , Gravel-Pack- Depth of Grout Sea J <br /> Cathodic Protection �:, - Rotary � Type of Grout <br /> Disposal `77• Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor M D <br /> Type of Pump H.P. <br /> PUMP- REPLACEMENT: C]State Work Dane <br /> PUMP REPAIR: ❑State Work -bone <br /> DESTRUCTION OF WELL: Well Diameter',�—__.. -gip * Approximate Depth <br /> Describe Materia an '' Proce ure . <br /> I hereby certify that I have prepared this-app"li-cat-i°on-and that the work will be done in accordana <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. " <br /> I WILL n <br /> L FOR OUT I ECTION PRIOR TO GROUTING AND F RL SPECTION. <br /> SIGNE TITLE: DATE: -/ <br /> (DRAW PLOT PL N ON RE E SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE Q-/_ <br /> f APPLICATION ACCEPTED BY _ -- <br /> ADDITIONAL COMMENTS : 921 --' <br /> PHASE II GROUT INSPEC7ION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ ,� DATE INSPECTION BY J° DATE /o <br /> co <br /> `�- _ <br /> 1178 2Mv <br />