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w SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFI—CE 'SE: 1601 E. Hazeltpn AN.e. , Stockton, CA 95205 Permit <br /> = ' Telephone:; (209) 466-6781 <br /> APPLICATION FOR WELL `CONSTRUCTION 0.9 PUMP PERMIT ' at : Issued23 �- <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 6 CITY/TOWN <br /> Owner's Name Phone <br /> Address City <br /> Contractor' s Name i' Ll cense Phone_r;Z /O 3 <br /> { x.4 j <br /> IS CERTIFICATE OF WO Kt1AN'S COMPENS IO"J INSURA"SCE 'O`N FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN [] RECONDITION ❑ DESTRUCTION[] <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 ti <br /> PUMP INSTALLATION ❑ PUMP REPAIR PUMP REPLACEMENT <br /> ❑ �s <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 SPECIFICAT O <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well-Casing _K 574 _44, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel—Pack Depth of Grout Seal <br /> Cathodic Protection Rotary t Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface-Seal Installed b :� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAII r:/, ❑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`idone in accordant. <br /> with San Joaquin County Ordinances, State Daws , and Rules and Regulations of the San Joaquin Loca-r, <br /> Health District. Home owner or licensed agent' s signature• certifies the followingi• . <br /> "I certify that in the performance of the work; for s permit is issued, I shall ' <br /> not employ any person in such manner,as to beee .subje.ct.- Workm . 's Compensation <br /> laws of California." �~ <br /> I WILL CALL. 0 A GROUT INSPECT PRIOR TO GROUTI AND A' F AL 1I •P IO <br /> SIGNED TITLE: DATE: <br /> DR W" PLOT PL N ON RE £ IDE <br /> "- -�' FOR DEPARTMEN E ONLY <br /> PHASE I t <br /> APPLICATION ACCEPTED BY DATE7-3 <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II G UT INSPECTION _ y PHASE III F JAL INSPECTION` <br /> INSPECTION BYZ=2 DATE - ��� 'INSPECTION BY DATE 5,=7� <br /> ru IAOC n-.. 10 '7'7 1 /7A 7M <br />