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SAN JOAQUIN LOCAL; HEALTH DISTRICT 3 <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued `? - <br /> This Permit Expires 1 Year From 5ate 'Is'sued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District -fdr a permit to construct <br />' and/or" install theawork herein described. This application is made_ in compliance with San <br /> 'oanuin County Ordinance No. 1862 and the Rules and Regulatioris . of the San Joaquin LocalHealth � <br /> �,istrict. <br /> EXACT STREET' ADDRESS (9.206 CITY/TOWN <br /> Owner' s Name 'Pho'he, s <br /> Address ® 2 CO. .- City <br /> Contractor' s Name Licenseg33 y[c17/ Phone <br />! _IS CERTIFICATE OF WORKMAN'S COMPENSATIOI! INSURAINCE ON FILE WITH SJLHD? YES NO <br />: TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTIONE2 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑' PUMP REPAIR❑ PUMP REPLACEMENT <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 />� C <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing a <br /> Domestic/public 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 by: <br /> PUMP INSTALLATION: Contractor. <br /> Type of Pump li.P <br /> PUMP REPLACEMENT: State Work Dane 2W t,J <br /> PUMP REPAIR: Q State Wbrk Done <br />( DESTRUCTION OF WELL: Well Diameter 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. " <br /> I WILL CALL FOR-A GROUT INSPECTION PRIOR ,TO GROUTING AND A FINAL INSPECTION. <br /> SIGN TITLE: DATE:7~ <br /> N "�- <br /> DRAW PLOT PL ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I <br /> APPLICATION ACCEPTED BY DATE ��_ <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHASE.-11FIN INSPECTION <br /> IINSPECTION BY DATE INSPECTION BY ATE <br /> FW 1A9r. Dau T7_77 1 /78 2.M <br />