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- I <br /> SAN JOAQUIN LOCAL HEALTH DISIR10- <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.ZL-6 9 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - <br /> i <br /> This Permit Expires l 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 des,cribed.. This application is made in. compli.ance with San <br /> Joaquin County Ordinance No. 1862 and the- Rules and Regulations of the San Joaquin Local Health <br /> E <br /> District. ZZ-7- I p <br /> EXACT STREET ADDRESS Sr E-` R� u'c�r Kit CITY/TOWN, <br /> Owner's Name Er Lf} Phone e- 7 <br /> Address . . L_0AXTac_v_ d.•.. City <br /> 3�S7s� .� S <br /> Contractor' s Name /��^ T *�_;¢_ _ _Li cense#3 Phone� _��_ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION' INSURAINCE ON FILE WITH SJLHD? YES NO � <br />,TYPE OF WORK .(Cheek-) : NEW-WELL 0 DEEPEN 0 RECONDITION DESTRUCTION <br /> WELL CHLORINATION Q WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION 0— PUMP REPAIR❑ PUMP REPLACEMENT Q v <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 R <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 <br /> Geophysical ` 15- Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump' w-_ � (e. - H.P. <br /> -- - - <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: O tate Work3Done <br /> _ : <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 <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 /> SIGNED TITLE: DATE: <br /> (DRAW PLOT PL N ON REVERSE SI E <br /> FOR DEP RTME T USE ONLY ;. <br /> PHASE I .. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> 7-/ IZIZ9— <br /> PHASE II GROUT INSPECTION PHASE III 9INAL ISP CTIA ` <br /> INSPECTION BY DATE �1r" INSPECTION BDATE� <br />