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� SAN JOAQUIN LKAL HEALTH DISTRICT <br /> FOR 'QFFICE USE: /1601 E. Hazel h Ave. , Stockton, CA 95205 Permit No. S� <br /> Telep.hone: , (209) 466-6781 <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued $'-3 7� i <br /> x )(9 <br /> This' Permit Ex ire's"l Year. From_Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit�to°construct <br /> and/or install the work herein described. This application- is .made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the. .San,.Joaquin Lacal Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN„ �l ar- <br /> Owner's Name Phone <br /> Address-2-,.,I .. City <br /> Contractor's Name LicenseK1� Phare <br /> FA URANCE I FILE WITH SJLHD? YES N0 <br /> IS CERTIFICATE-OF WORKMAN S COIMPENSATION Ila$ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTIONE3 <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ �- <br /> DISTANCE TO NEAREST: SEPTIC TAN l SEWER LINES- - PIT PRIVY <br /> SEWAGE DISP SRL/ FIELD CESSPOOL/SEEPhGE PIT OTHER= a� <br /> PROPERTY LINWd RIVATE�DO�! ESTIC WEL PUBLIC DOMESTIC WELL _:. <br /> INTENDEQ USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of- Well- .Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation =Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout r�F •�.� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal e b <br /> PUMP INSTALLATION: Contractor #' <br /> Type of Pump H.P. <br /> PUMPS REPLACEMENT: State Work 'Done-,.. <br /> PUMP REPAIR: `,C3State Work Done <br /> DESTRUCT-ION -OF WELL We-1-1 Diameter - - App-roximmate-Depth---- <br /> Describe Material and Procedure <br /> I 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' licehtEid-agent' s 'signature certifies the following: <br /> x "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 CA OR A GROVV INSPEC I T GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: ; . DATE: <br /> ! DR P O PL N ON REVE S ftr"E <br /> F DEPARTME T USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY . <br /> ADDITIONAL COMMENTS : <br /> PHA I GRO T INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY ATE INSPECTION BY DATE r� <br /> S�1 1 7.8VM <br /> - <br />