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SAN JOAQUIN LOCAL HEALTH .-DISTRICT <br /> LFQRFFICE USE: 1601 E. Hazelton Ave. Stockton,._CA 95205 Permit No ' - f <br /> Telephone: " (209) 466-6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued "�• ? <br /> This Permit Expires 1 .Year From Date Issued <br /> 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 application is made in compliance with San <br /> k'oaouin County Ord nance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. -a <br /> EXACT STREET ADDRESS 40 G T CITY/TOWNTd � <br /> Owner' s Name j-0 ti H M-DRAC Phone elo <br /> Address L/03q U)IL City STa t/�7t3/V . <br /> Contractor's Name W LLQ fAWPLicense# Z Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE om FILE WITH SJLHD? YES �O <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION M <br /> 4----�,,—WELL,• CHLORINATION-El--� WELL--ABANDONMENT Q- O.TH.ER_0- <br /> ' PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q T� <br /> DISTANCE TO-NEAREST. SEPTIC TANK SEWER LINES Z& PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE 0 CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation /z2 <br /> Domestic/private Drilled Dia. of Well CasingIt Z�r <br /> DaDa"15-stic/publid -s;�a �= Driven Gauge of Casingrigation Gravel -Pack Depth of Grout.,:Seal <br /> Cathodic Protection * Rotaryf <br /> Type of Grout <br /> . �.. -- ..fry <br /> Disposal Othr1F Other Information " <br /> Geophysical Surface Seal Instal. ed by: <br /> PUMP INSTALLATION: Contractor <br /> 3 Type of Pump H.P. <br /> , <br /> PUMP REPLACEMENT: Q State Work Done <br /> 3 <br /> PUMP REPAIR: E]State Work Done <br /> DESTRUCTION 0F .WELL: Well Diameter <br /> A � Approximate Depth <br /> — Describe-Material pan Proce ure <br /> I hereby certify that 14a•ve -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 1,3censed agent' s signature certifies the following: <br /> "I certify that in the.aperformance of the work -for which this permit is issued, I shall <br /> not employ anyy person" in such manner as to become subject to Workman's Compensation <br /> 4 <br /> laws of California." f <br /> I WILL WLL WR A; GROUT 1;NSPECT-ION PRIOR TO GROUTING AND A FINAL INSPECTION. ! <br /> SIGNED TITLE: w1ug DATE: ZS PIQ[L <br /> AV (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATE Y/-Z: <br /> [, <br /> ADDITIONAL COMMENTS : <br /> ` PHA E II GROUT INSPECTION PHASE, III FINAL INSPECTIO <br /> INSP.ECTION -BY j DAT£ INSPECTION BY DATE <br /> CLI l A'1]C n_.. n �l <br />