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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> TeTephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP. PERMIT Date Issued <br /> (Complete .In Triplicate) ' 0f3 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESSTY/TOW <br /> Owner's Name PhoneFK-I/-- S-S <br /> Address /1(U ,� Lu ('% .� City -- <br /> Contractor's Name License( y323 Phone!3 - 3� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO. <br /> TYPE-6F WORK (Check) : "NEW WELL L DEEPEN 0 RECONDITION ® DESTRUCTION rl <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION M PUMP REPAIR S • PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .., _ PIT PRIVY � - <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER 'w <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL. PUBLIC DOMESTIC WELL io <br /> ` INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Dril?ed- .. _ Di-a-. -of -Wel1.4asing ; wr <br /> Domestic/public - - Driven Gauge of Casing m <br /> Irrigation Gravel Pack Depth of Grout Sea + {� <br /> Cathodic Protection Rotary E Type of Grout <br /> ' Disposal Other Other Information <br /> Geophysical Geo h <br /> ` p y Surface Seal_ insta ed by: �T���• _ ,� � <br /> ¢ i <br /> PUMP. INSTALLATION: Contractor <br /> _Type of Pump t H.P. A o <br /> PUMP REPLACEMENT: Q State Work Done ; <br /> PUMP REPAIR: Ca-State Work Done c <br /> DESTRUCTION OF WELL: Well Diameter t ` Approximate Depth <br /> Describe Material and Procedure ; <br /> I hereby certify that I have prepared this application and that the work will be done in accordar <br /> with San Joaquin County Ordinances , State Laws, and Rules- and Regulations of _the. San .Joaquin Loci l <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. c <br /> I' WILL CALL F A ROUT I PECTION P IOR TO GROUTING ANPJ FINAL INSPECTION. <br /> SIGNED TITLE: DATE:I��`� 0 <br /> P ON REVERS E r <br /> R DEPARTMENT, USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - DATE-4/- <br /> ADDITIONAL <br /> ATE/,/-ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTIONrBYDATE I 71 <br />£H 14 26 RPv_ q/7R - ' 0/7Q -9M <br />