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{ [o► ° <br /> SAN J'OAQUIN LOCAL HEALTH DISTRICT <br /> FOR -OFFICE USE: 1.601 E. Hazelton Ave.:, Stockton, CA 95205 Permit No.7d JV1sY <br /> Telephone: . (909) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <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 work herein described. This application is made in compliance. with San <br /> Joaquin County Ordinance No:i 1862'and the: Rules and Regulations of .the San Joaquin Local Health <br /> District. <br /> { EXACT STREET ADDRESS . Q � �� - `' er CITY/TOWN . ' _ <br /> s <br /> Owner's Name Cd Phony <br /> Address, d 4 c.�s City <br /> Licensed phone F <br /> Contractor' s Name �'' _ l _ <br /> IS CERTIFICATE OF t4OPKtIAII'S ICO"i NSA IO"I I1111SURANCE ON FILE WITH SJLHD? ' YES NO <br /> E — <br /> { TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ �1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q <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 /> x Domestic/public Driven Gauge of Casing <br /> )e Irrigation Gravel Tack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout . <br /> Disposal i Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor w ,. ., <br /> Typeof Pump_... ff H.P. o <br /> PUMP REPLACEMENT: RIState Work Done 444e -t_ _ .r <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: WellliDiameter Approximate Depth <br /> Describe Material and Procedure <br /> r� <br /> I hereby certify that I have prepared this application and that the work will be done in accordani <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca' <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. " I <br /> I WILL CALL. FOR A GROUT INS1J1EC1I0NrP1t'I, R TO GROUTING AND A FINAL INSPECTION. <br /> s <br /> SIGNED TITLE: '.- DATE: <br /> . 19A,1,//17a? <br /> DRAW PLOT P& N ON REVERSE SIDE / f <br /> ` FOR DEPAR ENT USE ONLY <br /> PHASE I <br /> z APPLICATION ACCEPTED BY ,ma DATE <br /> ADDITIONAL COMMENTS: *� <br /> PHASE II GROUT 'INSPECTION PHASE III FINAL INSPECTION <br /> k INSPECTION BY DATE INSPECTION BY .9-S--9R_ _ DAT <br /> rii IAne' n_.: tin -7-r <br />