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SAS JOAQUIN LOGAL .HEALTH UISTRIL 1- <br />!" CA 95205 Permit No. �9- ,5 <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, <br /> Telephone: (209) .46676781 Date. Issued,g/4- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP .PERMIT <br /> This Permit Ex fres l 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 /> , oaquin 'County Ordinance No. 1862 and the Rules and Regulations ,of the San Joaquin Local Health <br /> C4strict. { <br /> EXACT STREET ADDRESS PhaneTOWN���gZ <br /> Owner's Name City <br /> Address <br /> Contractor' s Name Dt License# �6Phone - <br /> IS CERTIFICATE OF WORKMAN'S CO"iPENSATIO'N IINSURA"ICE OH FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 'KEPEN-CE] �R-,R ❑ DESTRUCTI.ONC] <br /> - WELL CHLORINATION 0 WEI�L"ABANDONMENT b OTHER <br /> PUMP IN'STALLATION fiQ PUMP REPAIR[] PUMP REPLACEMENT [I �- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY OTH£R � <br /> SEWAGE DISPOSAL FIELD^ CESSPOOL/SEEPAGE PIT <br /> PROPERTY LO E - PRIVATE/ OMESTIC WELL � PUBLIC DOMESTIC WELL � - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SP ECI;FICATIONS <br /> Industr,�ial Cable Too'] Dia. of Well -E.icoavatiora <br /> '` ' � rivate Drilled Dia. of Well Casing <br /> —Domes e/per' Driven Gauge of Casing <br /> Domestic/pUblli= . <br /> Irrigation - Graved Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type�of Grout <br /> Disposal 1 Other OtherInformation <br /> Geophysical Surface Seal Instal ed b <br /> PUMP INSTALLATION: Contractor, ; - H P - <br /> Type of Pump,f <br /> PUMP -REPLACEMENT: State Work Done <br /> PUMP REPAIR• QState Work 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 accordan <br /> with San Joaquin County Ordinanceas , State Laws , and Rules and Regulations of the San Joaquin Loca <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> `r.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 EOR,A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNSTITLE: DATE: - G-7 — <br /> (DRAW PLOT L N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> k <br /> PHASE I DATES <br /> APPLICATION ACCEPTED BY ` v <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA _ III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE-7— - ' <br /> r:l 4 ens n_.. <br />