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ASAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 601E.FFICE USE: Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> Thi.sV'Permit Expires .1 Year From Date Issued <br /> t Complete In Triplicate ; <br /> Application is hereby made to the San Joaquin Local Health 'District for a permit to construct <br /> an,d/or install the work herein described. This application is made in compliance with ,San <br /> k Joaquin County Ordinance No.. 1862 .and the Ruled and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESSW4 )PAV-1C"TT Y/TOWN <br /> Owner's Name u.&z� ,Z-J_ Cd Phone <br /> Address c. �J4�'7#F VCS City <br /> Contractor' s Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA"•ICE Om FILE. WITH SJLHD? YES ;a0 � <br /> TYPE OF WORK (Check) : NEW WELLS DEEPEN ❑ RECONDITION Q DESTRUCTION <br /> WELL CHLORINATIONQ WELL ABANDONMENT p OTHER# <br /> PUMP INSTALLATION El PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> r <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 DOMESTICWELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - <br /> Industrial Cable Tool Dia. of We ExExcavation ' <br /> Domestic/private Drilled Dia. of Well Casing ` <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump . H.P. <br /> PUMP REPLACEMENT: Staile Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter iv " + .� <br /> Approximate Depth f 5'a <br /> Describe Materi and Proce ure ue f� l <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 PRIO T GROUTING AND A FINAL INSPECTION. <br /> S I G N S <br /> TITLE: DATE: <br /> j W P - N ON REVERSE SIDE <br /> FO DEPA TMENT USE ONLY <br /> PHASE I i <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS.- <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION L DATE <br /> 97�9/-7,f <br />:H 142-6- - Rev_'.12'-77 <br />