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SAN JOAQUIN LOCAL HEALTH DISTRICT 3 <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 - Permit No. --11- <br /> - Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issue -J - <br /> This Permit Expires 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 />�oan.,in County Ordinance No. 1862'and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS- _ CITY/TOWN <br /> s� zX&/? D <br /> Owner' s Name ` ' Phone _346"2J! _I 4.1— <br /> Address. City 4 e,4 x-f 9 <br /> Contractor's Name Licensees �t-. -Phonefit/ <br /> IS CERT-I-FI-CAfiE OF-IdORKt4Atl'S�COfi9PEtISATIO"t-ItIS-URAlft'E-Ord-F7'LE-WITH-SJL'ND? YES <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ �. <br />]1STANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL- FIELD <br /> --CESSP,OOL%SE`EPAGE PIT OTHER � <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL-- \�sPUBLIC DOMESTIC WELL <br /> INTENDED USE ,/7YRE OF WELL CONSTRUCTION SPECIFICATIONS O/1 <br /> Industrial , 'Cable Tool Dia. of Well Excavation <br /> Lam-- mestic/private ' , .,rDr :lied Dia. of Well Casing <br /> Domestic/public �./ Driven•,, - Gauge of Casing <br /> &--trrigation ' .Graye1iPack Depth of Grout Seal <br /> Cathodic Protection btary Type of Grout -- <br /> Disposal Other Other Information �} <br />___-,_Geophysical Surface Seal Installed by: _ I <br />'UMP- INSTALLATION: Contractor n <br /> rfI Type of Pump <br />'UMP�-REPLACEMENT: FIState Work Done -- <br />'UMP-REPAIR: ❑State Work Done <br />)ESTRUCTION OF WELL: Well Diameter }� , Approximate, Depth <br /> Describe Mate ri a an ?rotedu_re <br /> hereby certify that I have prepa`redtithis applicati,onyand.`that �the_work_wi.l_lb-e done in accordance <br /> ri th San Joaquin County Ordinances-, State-Laws ; and�"Rul es and'-Regul'ati on-s 'of'lthe. San Joaquin Local <br /> Zeal t-fi District. Home owner or licensed agent' s signature certifies the. fo.T'Towi ng` ,'-f— <br /> I-)Icertify that in the performance of the work} far which this permit s issued, I shall <br /> not employ any person in such manner as to become subject to Workr�a'- Compensationtdl <br /> laws of California. " I r/ � - 4 <br /> WILL` CALL F R A GROUT INSPECTION PRID 0 GROUTING �'AND A FINAL INSPECTION. <br /> IGNED TIT ff: DATE:- Q <br /> (DRAW PinT PIAN ON .REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY- <br />'HAS E <br /> NLY'HASE kI <br /> PPLICATI-ON'ACCEPTED BY DATE <br />,DD IT IONAL COMMENTS: y, , <br /> PHASE II GROUT INSPECTION w <br /> PHASEJIi FINAL INSPECTION <br /> NSPE 7IW BY- - -..----DATE- _11NSP'ECTIO9 BY�tDATE -� <br /> 1426 ..Rev. .12-77 1 I7R 2 <br />