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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> PI�FFICE USE: 1601 E. Hazelton Ave. , Stockton; CA 95205 Permit No.Jg <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �g <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 Rja poi, pti CITY/TOWNcY <br /> Owner's Name Curs Phone e3.Y C F <br /> Address 3 27 c,�, TH XT. City '�A y <br /> Contractor's Name ,�? if cT/c r e License#!3°74'a o Phone gs-j'- /T <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION! INSURA"NCE ON FILE WITH SJLHD? YES I40 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION-CJ DESTRUCTION[] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION' 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 <br /> Industrial Cable Tool Dia. of Well Excavation ' <br /> ___7yDomestic/private Drilled Dia, of Well Casing G " 1 <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 j <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor r C_ <br /> -- <br /> Type of Pump _��� __- H.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 accordance <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 FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> S IGNED ,�'� TITLE: o / DATE: <br /> �DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : 1 <br /> PHASE. II GROUT INSPrECTION PHASE III FINAL INSPECTION <br /> ,E <br /> INSPECTION BY DATE INSPECTION BY DATE4 `,_23Y7,r- <br />