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MIF <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ;?���p8' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From. Date Issued <br /> Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a, permi,t to construct -�-,. <br /> and/or install the work herein described. -This application is made in compliance. with San <br /> Ioaqu�n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN .L4aC <br /> Owner's Name y �9 Phone 3419- 9-?)? 9 <br />-Address .SA11445City leczll - <br /> Contractor s Name Li cense#3 P 23 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES N0 <br /> TYPE OF WORK (Check) : NEW WELL_ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ c <br /> DISTANCE TO NEAREST: SEPTIC TANK A00-' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSALIELD CESSPOOL/SEEPAGE PIT: OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 5' <br /> Industrial ><Cable Tool Dia of Well Excavation 1.2 (� <br /> <Domestic/private Drilled Dia. of Well Casing �r <br /> Domestic/public Driven - Gauge of Casing - /a�'F. <br /> Irrigation Gravel Pack Depth of Grout Seal A-A <br /> Cathodic Protection Rotary Type of Grout dam 4ry 7- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal- Instal ed by:6WA10-A—, <br /> PUMP INSTALLATION: Contractor 60 W n/ E oe— <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State 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 accordant <br /> with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local <br /> Health 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 /> I WILL CA L FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: 6e - o-w- DATE: 99- <br /> DR W PL L N ON REVERSE SIDE <br /> PHASE I FOR DEP RTMEN USE ONLY <br /> PPS LICATION ACCEPTED BY G DATE <br /> ADDITIONAL ON L COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III -FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATEL7-'Z� <br /> H _ <br />