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Co SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -- - Stockton, CA 95205. Permit No. <br /> �FiCE USE; 1601 E. Hazelton Ave. , <br /> o Telephone (209) 466-6781 Date Issued <br /> .. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ices -..1,-Year From Date Issued <br /> LuS�rn® M.l+e �0 raw., Complete In Triplicate - <br /> 3 bi -J a0n ru v it <br />' Application is hereby made to the San Joaquin Local Health District..for. a permit to construct <br /> and/or. install the work herei`n' described. This application is made in compliance with San <br /> �'OdQuCounty Ordinance rtio:` 1862 grid the' Rules and Regul ati ons of the San Joaquin Local •Health <br /> District. <br /> E EXACT STREET ADDRESS "'"ra 1�s w=. ✓ CITY/TOWN �rti.,- <br /> I Owner's Name Phone <br /> Address '�.. City <br /> Contractor's Name <br /> Li cense# _ 1J Phone <br /> IS CERTIFICATE OF WORKMAN'S C NS TIOT1 IT SURAINCE OTS FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK .(Check) : NEW WELL 0 DEEPEN GIWELRECONDITION <br /> TT p DEOTRUCTIHER N❑ <br /> WELL CHLORINATION C3 <br /> PUMP INSTALLATION 0 PUMP REPAIR L PUMP REPLACEMENT El <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 /> . Domestic/public' Driven - Gauge of Casing <br /> h Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other . ,,Other Information <br /> f Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P._ <br /> PUMP REPLACEMENT: jO State Work Done ` <br /> PUMP ()State Work Done <br /> DESTRUCTION OF WELL: `Well Diameter Approximate' Depth <br /> k <br /> Describe Materia an 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 <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> "1 certify that in the performance. of the work for which this permit is_i-ssued, I shall <br /> not employ any person in such manner as to become subject to Workman' s Compensation <br /> laws of California. r <br /> II WILL CALL FOR A GROUT INSPEC N P OR'T GROUTING AND A FINAL INSPECTION. <br /> ITLE. DATE- <br /> # SIGNED DR PLOT PL ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I TE <br /> APPLICATION ACCEPTED BY <br /> -,ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE ' <br /> f. <br />