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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />—EOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ` _ ! 7 <br /> Telephone: (209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued,-I,;-?� <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application i 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 /> ,'oanuin County ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Distr4ct. <br /> EXACT STREET ADDRESS 1 /J-3 CITY/TOWN AI 71-�-- <br /> Owner' s Name r_ S T� Phone <br /> Address Sya City <br /> Contractor' s Name S-t1 License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATI01 INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT J�a- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY =s' <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. Z <br /> PUMP REPLACEMENT: M State Work Do e <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �3 <br /> Describe ateria and Procedure <br /> 2ru�7(l z e--e <br /> - <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 A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:-5—j--?, _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPLECTION PHASE,,-,III FI L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 142 �; f Z' )8 M <br />