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SAN JOAQUIN LOCAL. HEALTH DISTRICTFOS j <br /> FFICE�USE: i� 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: {209}' 4667.-681 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued �= <br /> This Permit Ex fres .1 Year. From .Date .Issued <br /> Complete In Triplicate <br /> a T <br /> Application is hereby made to the San JoaquinrLocal Health :District for a permit to construct. <br /> and/or install the work herein described. This application is made-.in compliance with San <br /> Loanuin County Ordinance No. 1862 and_.the Rules and Regulatianss-of the San. Joaquin Local Health <br /> bistr�ct. <br /> EXACT STREET ADDRESS . CITY/TOWN <br /> _r _ Phone Gbi';-O <br /> Owner' s Name <br /> Address Q Rd., City <br /> Contractor' s Name <br /> LicenseMRu7!_ Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION 0 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 /> Industrial Cable Tool Dia. of .Well Excavation <br /> Domestic/private Drilled Dia. of 'Well Casing_ <br /> r Domestic/public Driven Gauge- of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> s Cathodic Protection Rotary Type of Grout, .- i <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br />' PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work one <br />[.PUMP REPAIR. ❑State Work Done , <br /> DESTRUCTION OF WELL: Well—Diameter ry.n. Approx-i,mate- Depth -� <br /> Describe Material and Procedure <br /> 11'" '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 /> x not employ any person in such manner as to become subject to Workman's Compensation <br /> `. laws of California." <br /> I 'WILL CAL GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> I TITLE: DATE: -- $-7 <br /> SIGNI=D DRAW PLOT PLTN <br /> ON REVERSE SIDE <br /> f <br /> FOR DEPARTMENT USE ONLY ` <br /> PHASE I ^ DATE 5 <br /> APPLICATION ACCEPTED BY - . <br /> ADDITIONAL COMMENTS: <br /> ' PHASE II GROUT INS ECTION PHASE III FINAL INSPECTION <br /> 'INSPECTION BY DATE INSPECTION BY DATE <br /> E ,4r 1._ ..8 2 <br />