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r 7l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . FOR ff-1 E USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 77 113, <br /> Telephone: - (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued a- Z5� <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. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT .STREET ADDRESS I r`� CITY/TOWNr�� <br /> Owner's Name ' Phone 5 c1_- <br /> Address City ' v X<N <br /> Contractor's Name -U � 6_11�_'(S__� License— Phone 3 <br /> IS CERTIFICATE OF WORKMAN'S CO'iPENSATIO"! INSURANCE ON FILE WITH SJLHD? YES t✓' 'N0 <br /> TYPE OF WORK (Check) : NEW WELL W-- DEEPEN O RECONDITION C] DESTRUCTION[:) <br /> WELL CHLORINATION Q WELL ABANDONMENT C1 OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR CI 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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 5' � A V <br /> Irrigation Gravel Pack Depth of Grout Seal_ <br /> Cathodic Protection Rotary Type of Grout (7- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump --j- H.P. V <br /> PUW REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordan E <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 FORA ROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED• �,� TITLE: DATE: <br /> (DRAW PLUT LN ONREVRS I E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE- <br />, ADDITIONAL COMMENTS: /17 <br /> PHASE II GROUT INSPECTION PHASE III FI AL INSPECTION <br /> EINSPECTION BY DATE INSPECTION B DATE_2-�� F <br /> LoTf , r-aoir <br />