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! f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICR USE: 0/ 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - <br /> This Permit Expires 1 Year From Date Issued <br /> I` 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 /> Wean-,in County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br />- J1Str'Ct. <br /> EXACT STREET ADDRESS Q CITY/TOWN R <br />' Owner' s Name f Phone <br /> Address __T o City — T <br /> Contractor' s Name <br /> LicensefV <br /> �{� Phone- ��`z!!_ 2 - <br /> I' IS CERTIFICATE OF WORKMAN'S COMPENSATIOfa INSURAINCE ON FILE WITH SJLHD? YES 4-----jq0 <br />' TYPE OF WORK (Check) : NEW WELL Pr--_D-EEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 � <br /> i PUMP INSTALLATION ❑ - PUMP REPAIR❑ PUMP REPLACEMENT [1 a <br /> r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD -CESSPOOL/SEEPAGE PIT OTHER G <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC 'WELL <br /> INTENDED USE TYPE OF WELL f + ;CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.-/of Well Excavation / <br /> mastic/private Drilled Dia. ' of ,Weld Casing ' 4, <br /> Domestic/public Driven Gauge of.Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 9 <br /> Cathodic Protectionteary Type of Grout S-o' <br /> E Disposal Other Other In ormation <br /> Geophysical Surface ,Seal Installed b <br /> ._F. <br />', PUMP INSTALLATION: Contractor L_ <br /> Type of Pump- H.P. <br /> PUMP REPLACEMENT: ❑ State Work-4Donoe <br /> PUMP REPAIR: ❑State Work. Donee, -- - <br />`DESTRUCTION OF WELL: Well Diameter _ h � ` Approximate Depth <br /> Describe Material an- Procedure <br /> I hereby certify that I have prepared-,this application and that the work will be done in accordance <br /> with Sah 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, fo.r 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 RO TING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: L <br /> DRAW PLOT�PL ON REV SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ° DATE 7- 137 <br /> ADDITIONAL COMMENTS: k. <br /> PHASE II GROUT INSPECTION PHASE III FINAL NSPECTION <br /> INSPECTION BY DA INSPECTION BY DATE �- <br />