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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFI E USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.,z9_,4 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITV L001 <br /> 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 Local Health <br /> District. <br /> EXACT STREET ADDRESS 3 ,� ,, a 1 CITY/TOWN <br /> Owners Name Ca�a/Q/0.W& jl/. �,, os Jell Phone <br /> Addressr <br /> G 2-3 �a4n ism _ city <br /> Contractor's Name License# i,43-)s.=Phone mai -:24 2'/— <br /> IS <br /> `LIS CERTIFICATE OF WORKMAN'S COMP S TION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 04 RECONDITION [] DESTRUCTION( <br /> WELL CHLORINATION Q WELL ABANDONMENT0 OTHER 0 <br /> PUMP INSTALLATION M PUMP REPAIR 91 PUMP REPLACEMENT C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL F ELD CESS�OL/SEEPAGE P11=— OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC D ESTIC 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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: RState Wor 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 accordance <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 CALL FOR GROUT INSPK5,IOM PRIORTO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TLE:�� i- DATE: <br /> L L ON REVERSE SIDE <br /> PHASE I DEPARTMENT USE ONLY <br /> PPS LICATION ACCEPTEDe., <br /> J DAT <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY YIA= _ DATE INSPECTION BY DATE 1_3 1-,�j <br /> EH 14, 26 Rev. 9fr8 9 78 2M <br />