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Com 1.�oGQ - , 'SAN JOAQUIN LOCAL!HEALTH DISTRICT <br /> )FFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issub IA3 <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 permit to construct <br /> and/or install the wo�V <br /> bed. This application . is made in compliance with San <br />[ : oapu;n County Ord . 1862 the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> O <br />` EXACT. STREET, ADDRESS ,h 1)�-Z- , CITY/TOWN <br /> Owner's Name ' <br /> Phone <br /> Address -- �.�'�- city <br /> Contractor's Name A License# hone � <br /> IS CERTIFICATE OF WORKMAN'S COM dSATIO"! I'�TJSURANCE ,Ott FILE WITH SJLHD? YES NOr <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> ,WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION 5d PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE-1-6 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/public <br /> omestic/pr.ivate DrilledDia. of WellCasing 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 b <br /> PUMP INSTALLATION: Contractor 4A< <br /> Type of Pump . ` / H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP R ��: []State -Work-Done <br /> DESTRUCTION OF WELL: Well Diameter ` <br /> Approximate Depth <br /> Describe Materia and Proce ure - <br /> I hereby certify that I have prepared this appl,icationf-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 `wo'rk for which this permit is issued,, I shall <br /> not employ any person in such manner- as,.,to become'•s-ubject..to Workman's Compensation <br /> laws of California. <br /> I WILL CALL FOR A GROUT INSKsQTIAN P R TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED c ITLE: rs `,� _ DATE: <br /> DR W PLOT PL N;ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I <br /> APPLICATION ACCEPTED BY € DATE� .,-8�g <br /> ADDITIONAL COMMENTS : - i <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTIONpp <br />[NSPECTION BY DATE INSPECTION BYOt <br /> DATE [a <br />:H 1426R 12' Y ` <br /> o �.. <br />