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i <br /> E `1 SAN JOAQUIN LOCAL HEALTH DISTRICTI FOB permit No. <br /> FFICE USE: 1601 E. Hazelton Ave.., Stockton, CA 95205 <br /># Telephone: (209) 466 .6781 Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Thi s . Permit Expires 1 Year From Date Issued <br /> r Complete In Triplicate , <br /> Application is hereby made to the San Joaquin Local -Health District for a permit to construct <br /> and/or install the work herein described. This: app.lication is made i.n. compliance with San <br /> Joaquin County Ordinance Np., 1862 and the Rules and Regulations of the San- Joaquin Local "Health <br /> . r <br /> District. <br /> E CITY/TOWN N' <br /> EXACT.STREET ADDRESS <br /> Owner's Name L, Phone <br /> Address _ <br /> City <br /> Contractor' s Name = r, <br /> License# , -Phon <br /> k. <br /> IS CERTIFICATtE 'OF WORKMAN'S COMPENSATION TNSURA�dCE ON FILE WITIi SJLND? YES ✓ NO % <br /> TYPE, OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ® '. DESTRUCTION rl <br /> WELL CHLORINATION Q WELL ABANDONMENT OTHER ❑ <br /> PUMP INSTALLATION PUMP REPAIR E3PUMP REPLACEMENT C� <br /> a 4 <br /> I DISTANCE TO NEAREST: SEPTIC TANK E4tlER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER a. <br /> PROPERTY LINE PRIVATE DOMESTIC WELL _kf^ PUBLIC D:OME5TIC WELL _ — <br /> . _ <br /> INTENDED USE TYPE OF WELL � 4 vCONSTRUCTION-;S.PECIFICATIONS <br /> Industrial Cable Tool Dia. of W611 Excavaation' <br /> Domestic/pri.vate. Drilled Dia. of Well,Casing <br /> Domes tic/publ-c Driven Gauge of Casing <br /> Irrigation . <br /> Gravel ,Pack Depth of Grout Seal <br /> Cathodic Protection ��_Rotary: Type of Grout <br /> Disposal Other Other Information <br /> Geophysical,, <br /> r' Surface Seal Installed b <br /> PUMP• INSTALLATION: Contractor H P <br /> Type of Pump <br /> #1 w <br /> 'PUMP REPLACEMENT:. Q State Work Done e '+- <br /> PUMP REPAIR:��� Q State Work Done <br /> � ro�ximate�De th <br /> DESTRUCTION OF €LL. WeII lDiameter �� APP. �' <br /> t Describe Material 'and Procedure .- <br /> 77 <br /> I hereby cerci fy that I havew.p.i^epar.ed thi s'-4 p 0-1 eats on sand that Rthe work will be done in accordan <br /> �' th San Joaquin Co 'nty Q'r finances, State.. Laws and Rules and Regulations of the San Joaquin Loca <br /> . .. <br /> .tt,, District. , Home owner or`1 i censed agent,' s s i gnatui^e c`ertFi f i es the following: <br /> I"Y certify that i n r the performance of the work for which this permit is issued, I shall <br /> not emplpy any person:,in such ,manner as to become subject to Workman' s Compensation <br /> law's of Cal i forn'i a ".- <br /> `I WILL CA FOR A UT IIVSPlCTION PRIOR TO GROUTING AND A FINAL INSPECTION, <br /> ,. T E: f ,. DATE: <br /> SIGNED T PL N ON REVERSE SI E <br /> i>i D W PL <br /> 4 f FOR DEPARTMENT USE ONLY .. <br /> E <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL. COMMENTS: <br /> PHASE II OUT INSPECTION PHASE III F kAL INSPECTION <br /> INSPECTION BY DATE �-% -�7� INSPECTION BYC' -,r DAT3 <br /> - 1 78 r <br />