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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> nFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.x-- <br /> Telephone.: >(209) .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued4 <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 RegulAti.ons of the San Joaquin Local Health <br /> District. ��s <br /> UACT'STREET ADDRESS r CITY/TOWNr ; <br /> Owner's Name Phone114 3- .5 ,2_ <br /> Address.. —. <br /> City. <br /> Contractor's Name L _cense Phone / <br /> F <br />,IS CERTIFICATE OF WORKMAN'S CO";PENSATION INSUR INCE ON FILE WITH SJLHD? YES <br /> TYPE OF =WORK (Check) : NEW WELLM DEEPEN p RECONDITION DESTRUCTION(�. _ r, . . <br /> V WELL CHLORINATION Q WELL ABANDONMENT ® OTHER 0 <br /> PUMP INSTALLATION M PUMP REPAIR 0 PUMP REPLACEMENT Q b <br /> DISTANCE' TO NEAREST: SEPTIC TANK,, SEWER LINES,<--p,`{. PIT PRIVY ---- <br /> SEWAGE 'DISPOSAL FIELDS 1+ CESSP 0L/SEEPAGE PIT --@THE� -- <br /> �,..w , <br /> PROPERTY LINELo"Ir NATE DOMESTIC WELL L . PUBLIC DOMESTIC WELL <br /> i - r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS F <br /> Industrial ' X Cable Tool Dia. of Weil Excavation' y- <br /> omestic/private Drilled Dia. of Well Casing 19 . <br /> Domestic/public Driven Gauge of Casing <br /> I rri ati on _1Q— ta :l..l <br /> g Gravel- Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> 4Disposal Other Other Information <br /> -- Geophysical a <br /> �' �� <br /> Surface Seal Installed b <br />'UMP INSTALLATION: Contractor - <br /> Type of Pump <br /> H.P. <br />'UMP+REPLACEMENT: [2 State Work Done . <br />'UMP-REPAIR: Q State .Work Done _ s7 <br />?ESTRUCTION OF WELL: Well Diameter '„ <br /> Approximate <br /> Describe' Mater a an Procedure <br /> Depth c <br /> hereby ce.rti fy_that--I have.apr-epared,-th,i s-application and, that-the work wi 11 be done-i n accordance{ <br /> lith San Joaquin County Ordinances ;- State Laws, . and Rules .and Regulations of the -San Joaquin Local <br />'ealth '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. + <br /> WILL-CALL FOR G UT, PECTION PRIOR TO GROUTING AND A"FINAL"I-NSPECTION.' <br /> IGN.ED - TITLE: 14 llslkw� DATE: t f <br /> Kff N ON REVER IDE <br /> HASE 'I - <br /> F DEP TMENT USE ONLY <br /> v . .. ._.�. , <br /> rP ICATION ACCEPTED BY �TE <br />)DITIONAL COMMENTS: <br /> ;PRASE II GROUT INSPECTION 1 <br /> ISAECTION BY PH SE I INSPECTION <br /> I 14 26 Rev. 9/ <br /> DATE INSPECTION 8 DATE <br /> - � <br /> 470. ou <br /> �� <br />