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_. T�_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE VSE,:"-, 1601 E. Hazelton,Ave, Stockton, CA 95205 Permit No. <br /> Telephone: "t209) 466_.6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued5-/0-7 <br /> This Permit Ex fres 1 Year From. Date Issued g. <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'wdrk 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 /> District. <br /> EXACT- STREET ADDRESS CITY/TOWN <br /> Owner' s Name P_ Phone <br />' Address .. . .. _ <br /> Contractor's [Name.a ' Li cense#� X1'3 Phone $.2.2-�/ _ / <br /> IS CERTIFICATE .OF WORKMAN'S OP•iP,ENSATIO�i INS A*•iCE�ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK .(Cheek-)'`:tiNEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION E3 WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT C1 �1 <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 WELLCONSTRUCTION SPECIFIC TIONS <br /> Industrial Cable Too1 Dia. {of Well Excavation <br /> 'Domestic/private Dri11ed Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing j <br /> E Irrigation -Gravel ..Pack . __ Depth of Grout Seal <br /> + . Cathodic Protection .- b,,- Rotary Type of Grout <br /> t Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed b : <br /> PUMP INSTALLATION: Contractor } <br /> ype of Pump ' H.P. <br /> ; PUMP REPLACEMENT: [ State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> ( DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 Procedure <br /> II hereby certify that :I have prepared this application and that the work will be done in accordant <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." 1 <br /> ' I WILL CALL F R A GROUT INSPECTION PRIOR TO GROUTIN FINAL IMOECTION. <br /> '. SIGNED -- TITL - DATE: <br /> (DRAW PLOT PLAN ON RE SMS DE <br /> FOR DEPARTMENT ISE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: y <br /> PHASE. II. GROUT INSPECTION' PHASE III FINAL INSPECTION <br /> •INSPECTION BY DATE � INSPECTION BYE <br /> "'2M <br />