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' SAN JOAQUi.P! -L'OCAL� H5AI�TFi DISTRIC'T <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95206 Permit No. J <br /> Telephone: _ <br /> p (209) .466-b781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -J ��7 <br /> This.-Permit Expires i Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to -the San Joaquin Local" Health .Distr.ict for a' permit to construct <br /> and/or° install the work herein described. This application is made incompliance with San <br /> ,oaauin County Ordinance ado. °1862 and, the Rules and Regulations of the San Joaquin Local : Health 4 <br /> Distract. { <br /> EXACT. STREET ADDRESS / - i <br /> CITY/T0WN5;Prc u <br /> Owner's Name - ? <br /> Phone -- O 6 <br /> Address A <br /> Ci ty. e <br /> Contractor's Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSAT.. INSUR "10E ON FILE WITH SJLHD? YES NO l <br /> TYPE OF WORK (Check) : NEW WELL a DEEPEN ❑ RECONDITION t <br /> WELL CHLORINATION ❑ WELL ABANDONMENT DESTRUCTION❑ � <br /> PUMP INSTALLATION ❑ PUMP REPAIR L--- PUMP REPLACEMENT ❑ O <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 WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled , Dia. of Well Casing "Zi <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation G-ravel 'Pack Depth of Grout Seal <br /> Cathodic Protection Rotary _ _.Type of Grout-"- <br /> r <br /> - Disposal _ � � n Other- ­-Other- Information <br /> Geophysical '" ` = '� Surface Seal Installed b y <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br />'UMP REPLACEMENT: ❑State Work Done <br />)UMP REPAIR: <br /> (i-State Work Done ,gdd �,�_( �,,_ �c�� � cloa.��� �, h._n. . <br />)ESTRUCTION OF WELL: Well Diameter '�� -- - _ <br /> Describe Materia and Procedure Approximate Depth <br /> hereby certify that I. have prepared this application and that the work will be done in accordance <br /> lith San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin ocal � <br /> lealth 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 <br /> laws of California. " n <br /> as to become subject to Workman's Compensation -,- <br /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED wn TITLE: DATE: ga. <br /> DRAW PLOT PL N ON REVERSE SIDE �7 <br /> Ze <br /> . <br /> ` J ; I FOR DEPARTMENT <br /> HASE I' USE ONLY i <br /> PPL ICATION ACCEPTE-D"BY $ ':. . DATE �- 3 <br /> DDIT IONAL COMMENTS : t a a Ir 7 <br /> PHASE II GROUT INSPECTION <br /> PHASE III FINAL INSPECTION <br /> VSPECTION BY� <br /> DATE INSPECTION BY DATE I <br /> 1 1426 ..Rev_ 12' -77 <br />