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it <br /> �r <br /> SAN JOAQUIN �LOCAL HEALTH 01SfRIC1 <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.Z�L_ <br /> Telephone: (209) 466-6781 <br /> A-41 11 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This. Permit Expires 1-Year .From !Date Issued <br /> Complete In Triplicate <br /> Applicationis hereby made to the San Joaquin Local HealthiDistrict for a permit to construct:. -- <br /> and/or install the work herein described. This application is made in compliance with San <br /> I'oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health/ <br /> District. �! <br /> 4: <br /> EXACT STREET ADDRESS ✓ CITY/TOWNG �°� y <br /> Owner' s Name i! Phone F3 <br /> Address .5 - - - % City <br /> Contractor's, Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE !'WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW-WELL M) DEEPEN ❑` RECONDITION ® DESTRUCTION[2 <br /> WELL CHLORINATION-0-WELL ABANDONMENT[3,OTHER.O <br /> PUMP INSTALLATION PUMR,,REPAIR C- PUMP REPLACEMENTS <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES` j'PIT PRIVY <br /> SEWAGE DISPOSAL _FIELD _10ESSPOO '/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE "� "TYPEOF WELL' --., :CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tooli­ --Dia:- of Well Excavation <br /> Domestic/private Drilled t 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 Others <br /> ,,;Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: -.:[],State,,:Work Done.. <br /> i; <br /> PU QState• Work. Done - !! <br /> ESTRUCTION OF WELL: ell 'Diameter Approximate Depth <br /> Describe Materia and Procedure /l <br /> f�C� ✓FLU �G /�O �2� Q, o- &-Area^F_e� 6 OfnJh�T1 <br /> I hereby certify that I have prepared this application andithat 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 /> "II 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." l <br /> I WILL CALL kOR A GROUT N .PEC ON PRIOR TO GROUTING AND AIFINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DRAW PLOT PL N ON REVERSFSIDE ! <br /> FOR DEPARTMENT USE ONLY j <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE � -7 <br /> ADDITIONAL COMMENTS : ' <br /> PHASE II GROUT INSPECTION i PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />