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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave: , Stockton, CA 95205 Permit No. 75r=� 1/ 91 <br /> Telephone: (209) 466,-6,781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued yf. - 8� <br /> This Permit Ex ices 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 /> q <br /> and/or install the work herein Idesciibed. 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. N <br /> EXACT STREET ADDRESS i /`�' LacrQ law a��r' TY/TOWN <br /> Phone <br /> Owner's Name <br /> a � <br /> C i ty <br /> Address . <br /> Contractor' s Name <br /> License# 6 Phone <br /> IS CERTIFICATE OF WORKMAN'S 6MPENSAA011 IINSURA110E ON FILE WITH SJLHD? YES <br /> TYPE OF WORK- (Check) :. NEW WELL L DEEPEN 0 RECONDITION; -DESTRUCTION C] <br /> WELL CHLORINATION 0 - WELL-ABANDONMENT 0 OTHER 0 — <br /> PUMP INSTALLATION C PUMP REPAIR❑ PUMP REPLACEMENT <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 o <br /> Industrial Cable Tool Dia. of Vel-F Excavation <br /> *r <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. l <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure <br /> I hereby certify that I ,havelprepared this application and that the work will be done in accordant( <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home ownerlor 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 C L F R A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: .. _ DATE: <br /> E R W SLOT L N ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: 4 <br /> PHASE: II GROUT 'INSPECTION PHASE III FINAL INS T <br /> {.INSPECTION Y DATE INSPEC`T`ION BY \4'Z D <br /> ' .- O` a�C� ---�`�� �...�. �/-Y' ^� V�`• - �.-4-_ ^' :,rte-.'-'` / M, <br />