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SAN JOAQUIN LOCAL HEALTH DISTRICT-� �- <br /> XCE USE: .� 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7L/a6 <br /> .APPLICATION <br /> Telephone: (209) 466-6781 <br /> FOR -WELL „CONSTRUCTION OR PUMP PERMIT Date Issued 7 <br /> �� <br /> This Permit Ex i res. 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' Loca1 Health <br /> !district. ' <br /> EXACT STREET ADDRESS CITY/TOWN_S_� <br /> Owner's Name iE 46 <br /> Phone i? _ /y/ <br /> Address Z City <br /> Contractor's Name��r, ��L �� . License_ Phone_��,7�.2,Q/Q _ <br /> IS CERTIFICATE OF WORKMAi!'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES Ay NO <br /> TYPE OF WORK (Check) : NEW WELL[i DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION [1 WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT C 04 <br /> DISTANCE TO NEAREST: SEPTIC TANS SEWER LINES --- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEP GE PIT OTHER -- <br /> PROPERTY LINE/a,tPRIVAT�ESTIC 'WELLc� 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 4V <br /> T Domestic/public �'I, - Driven ^" Gauge of Casing fjr <br /> Irrigation " # Gravel -Pack Depth of Grout Seal Q IJ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> 4 <br />` PUMP INSTALLATION: Contractor - <br /> Type of Pump -- H.P. _ <br /> R. <br /> PUMP' REPLACEMENT: F] 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 accordancf <br /> with San Joaquin CountyOrdinances , 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 GR Ti�INS EC ON OR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: <br /> T N DATE: �d �,(�I,,-, <br /> W PL PL ON REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> APPLICATION ACCEPTED BY . �� DATE // �" <br /> ADDITIONAL COMMENTS: <br />' <br /> PHASE GROUT INSPECTION F PHASE III NAL INSPECTION <br /> INSPECTION -B_ We4 DATE 07 -,2y__7� INSPECTION BY DATE Z � <br /> FH 1426 Rev: 12=77 0d. .W�'�C- :. . k _] 178 2M' <br />