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II <br /> li SAN JOAQUIN LOCAL HEALT DISTRICT <br /> F1=ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> -' This -Permit Ex i res 1 Year From Date Issued—" 4 <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 /> ,oaq,1,in County Crdinance No.01862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. !i <br /> EXACT STREET ADDRESS l CITY/TOWN <br /> .. - <br /> Owner' s Name Phone <br /> Address City=—, <br /> Contractor's Name b License Phone_ /' �/ =1 2, _ <br /> IS ,CERTIFI"GATE OF WORICr9RN'"S ?C0PIPENSAT'Icl"J"i�1 EOPIFILE= WIT}1-SJtHD?-�`�YS�--z�- - td0 ; <br /> P, - - <br /> a._ <br /> TYPE OF WORK (Check) : NEW WELL @a , DEEPEN C RECONDITION,C] DESTRUCTION[2 - <br /> WELL CHLORINATION Q WELL ABADONMENT 0 OTHER 0 - - IN, <br /> PUMP''-INSTALLATION D PUMP REPAIR❑ PUMP REPLACEMENT E] GJ <br /> DIST ANCE"*TONEAREST: ASEPTIC TANK.EWER LINES PIT PRIVY <br />'t 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 j Cable Tool Dia. of Well Excavation ,/dal ` __- <br /> 4,-&..8omestic/private Drilled Dia. of Well Casin g <br /> Domestic/public Driven Gauge of Casing _ 10 <br /> 4--l—trri gati on fl Gravel Pack Depth of Grout Seal Ae <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b 1 <br />: PUMP INSTALLATION: Contractor ` <br /> Typeof Pump <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 accordance <br />, with San Joaquin County Ordinances_, State Laws , and Rules and Regulations of the San Joaquin Locale <br />. Health District. Home owner or li.censed�"'agent' ssignature 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 i.n such manner as to become subject to Workman's Compensation <br /> laws of California. <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR T_Q WOUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 02 <br /> (DRAW PLOT PLAN ON REVERSE SIDE t, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE. . t1.'DATE <br /> t}7N. ACCEPTED BY <br /> " ,COMMENTS: - <br /> PHASE II GROUT-.iINSPECTION I PHASE III FINAL`fNSPEC <br /> s ''Y I DATE ' INSPECTION BY _. D. <br />