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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> HICEUSE: 1601 E. Hazelton Ave. , Stockton, _ <br /> CR 95205 Permit No. <br /> Telephone; _(2(19;• 466-67$1 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -16-7g <br /> (tomplete 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 Sari <br /> Joaquin County Ordina ce No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. D <br /> EXACT STREET ADDR ' <br /> CITY/TOWW �.. . <br /> Owner's Name <br /> Ai wr:44aAa , <br /> Add Phone ° <br /> a ° <br /> Address s r . Ci ty •� u# <br /> Contractor'sNam <br /> 1 rn> License# Phone <br /> tI <br /> IS CFRTIFICATE OF WORKAN`S COIAIPENSATION ItdSU�ANCE ON FILE WITH PSJLHD? YES <br /> 0 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN O RECONDITION [D DESTRUCTION( <br /> WELL CHLORINATION O WELL ABANDONMENT O OTHER O <br /> PUMP INSTALLATION Q PUMP REPAIR O PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK//V,* SEWER LINES PIT PRIVY'"" <br /> SEWAGE DISPOSAL FIELD#fhe� { CESSPOOL/SEEP,AGE PIT ,,_. OTHER `"'" '-� <br /> PROPERTY LINE 4PRIVAT—DOMESTIC WELL` °'" T PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 4 r <br /> Domestic/private Drilled Dia. of Well Casing �► <br />.Domestic/public Driven Gauge of Casing,—/I � r <br />—_Irrigation t l <br /> _____Gravel Pack Depth of Grout Sea - , ti r <br /> t. <br />��Cathodic Protection — 4, otary Type of Grout ,. ',> <br />_.,____Disposal Other Other Information <br /> Geophysical Surface Seal Instal—lea by; l„a,rr <br />'UMP INSTALLATION: Contractor <br /> Type of Pump H. . <br />'UMP REPLACEMENT: ❑State Work Done <br />'UMP REPAIR: ❑State Work Done <br />}ESTRUCTION OF WELL: Well Diameter <br /> Describe Materia an Proce ure Approximate Depth <br /> a <br /> hereby certify that I have prepared this application and that the work will be done in accordancd <br />!ith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local ' <br />`ealth 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 a <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. ” <br /> WILL CALL FOR A ,GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED <br /> r. TITLE: DATE: " <br /> R W L N ON REVERSE SI E <br /> BASE IOR DEP RTMENT USE ONLY [tf <br />'PLICATION ACCEPTED BY <br />)DITIONAL COMMENTS: DATE <br /> PHASE iI GROUT <br /> lSPECTION BYINSPECTION PHASE III FINAL INSPECTION <br /> ` DATE t <br /> 1 14 26 Rev. 9/7R INSPECTION BY DATE t <br />