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SAN JOAQUIN LOCAL-.HEALTH DISTRICT - ----- - - <br /> JFF• CE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> w Telephone: (209) 466-6781 fir, <br /> 24 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> This .Permit Expires 1 Year From Date Issued . <br /> Complete In Triplicate j <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 /> Joaqui-n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS � �- � CITY/TOWN I <br /> Owner's Name - -,Z.i;p Phone Jc5-,J,—w -gee4 <br /> { <br /> Address <br /> Contractor's Namee5;Z-7/__3 f&6;r., , e License&2&rte, Phone <br /> a <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES ""`' NO <br /> TYPE OF WORK (Check) : NEW 'WELL❑ DEEPEN ❑ RECONDITION C3 DESTRUCTION(❑ <br /> WELL CHLORINATIONJE3 WELL ABANDONMENT 0 OTHER <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ oQ <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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. i <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 /> A I <br />._I-hereby-certify that-I__have_.prepared-ithis._�a'ppl.,ication and.-that -the-work wi1_1__be--done in accordanc <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Locale <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 FO, A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. f <br /> SIGNED TITLE: DATE: <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � tz - DATE / 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3 <br /> T 17'A 2M <br />