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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE 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 /> i (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 Local Health <br /> District. <br /> �XACTREET ADDRESS "` CITY/TOWN rne <br /> Address Phonq��� "�s <br /> ` �- C i ty- �= <br /> Contractor's amQ24A,40�62L4 e License��9�_ PhoneZg _�25d <br /> IS CERTIF CATS OF WORKPIAN'S CO3"PENSATION INSURACNCE ON-FILE,WITH�S.J.LHD?I.\ YES 4--- 0 <br /> TYPE OF WORK (Check) : NEW WELL CO DEEPEN 0 RECONDITION"O ' DESTRUCTION[ � <br /> k WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION (,� PUMP REPAIR❑ PUMP REPLACEMENT Ej <br /> DISTANCE TO NEAREST: SEPTIC TANK O ' SEWER- LINES PIT PRIVY - <br /> SEWAGE DISPOSAL FIELD�rCESSP00L/SE AGE PIT , OTHER <br /> PROPERTY LINE a�PRIVATE DOMESTIC WELL a PUBLIC 'DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> In ustrial Cable Tool Dia. of Well Excavation <br /> _ , <br /> �_Domesti�rivate . D.ri_lled _ m.p of We11,�Casi-ng -/' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack--Dept-h=--of-Grout ea <br /> Cathodic <br /> Protection Rotary Type of Grout <br /> Dis <br /> Disposal <br /> Other Other _Information, <br /> Geophysical Surface. Seal, I•nsta ed b <br /> PUMP <br /> IN Contractor <br /> "tet Type of Pu p <br /> s v <br /> H.P.Te <br /> r <br /> PUMP REPLACEMENT: Q State�Work Done <br /> iPUMP REPAIR--; []Sta-te Work Done: '' r <br /> DESTRUCT,ION�;OF WELL: '' ti+lel'1 Diameter Approximate Depth', <br /> Describe Material and.-Proce ure <br /> I hereby certify that I have prepared thissapplicatio6 and that the work will be done in accordance <br /> with San Joaquin County Ordinances , ;S'tate Laws,a-nd-Rules and Regulations of the San-Joaquin Local <br /> Health District. Home owner :or., 11�eased agent's signature certifies the following: <br /> "I certify that in the pe'rformance-of the work for which this permit is issued, I shall <br /> not employ any person in such manner as to become- s.u.b 'Jec-t=to-Workman's-Compensati-on <br /> laws of California. <br /> j,--WILL CALL FOR A 0 T I SPECT N PRIOR TQ GROUTING AND A"FINAL INSPECTION. <br /> SIGNED TITLE: DATE: "' <br /> _ -2� . <br /> RAR PEOT 7LLN- ON REVERSE SIDYTT - <br /> PHASE I - �,�..�`"' 0 DEP RTME T USE DNLY - ^ <br /> APPLICATION ACCEPTED BY - DATE --��z�' <br /> ADDITIONAL,COMMENTS:. r <br /> Pca <br /> HASE II G OUT IN ECTIO RASE Ill FINAL INSPECTION <br /> INSPECTION BY DATE j <br /> INSPECTION BY DATE-7-,L]--?? <br /> EH 14 26 Re /78 0„Q ')FT , <br />