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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.z � <br /> Telephone:., (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ S- <br /> E This Permit Ex ires 'l Year From Date Issued <br /> Complete In Triplicate ; " <br /> Application is hereby made t the San Jo uin Local H 7?L2 <br /> and/or q ealth District for a permit to construct <br /> nstall the work hereiin described. This application is made in compliance with San <br /> lru'oaquin County Ordinance ado. X1862 and. the Rules and R gulations of the-'San Joaquin Local Health <br /> ' District. <br /> EXACT STREET ADDRESS• . S4el �J <br /> Owner's Name <br /> ' CITY/TOWN f 01".1 <br /> Phoneal!— � . <br /> Address O <br /> `Ci ty <br /> Contractor's Name G �r� _ , . <br /> i fes. �enseA,3�S*_.Ia Phone <br /> IS CERTIFICATE OF. WOi'.KPiAN'S COi~iPENSATIOIN INSURANCEON FILE WIT+f�JCFf6? . YES 1NO' <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ RECONDITION <br /> WELL CHLORINATION 0 WELL ABANDONMENT p QEOTHERT0 N[� <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAG r <br /> PROPERTY LINE -. PRIV / E PIT OTHER �. <br /> ATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL. - � <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cab'�le Toole . Dia. of-Well Excavation <br /> Domestic/private t Dri.l, � Dia. of Well Casing , ' <br /> led �, ,•, <br /> Domestic/public 1. i Driven 'w Gauge of Casing g -Ar <br /> _Irrigation I ; Gravel -Peck ''' Depth of Grout Seal ' <br /> Cathodic Protection x I Rotary f_� Type of Grout ;, <br /> Disposal { I Other <br /> Geophysical Other Informations <br /> �" '=:___--;Sur:face Seal%Lns'tal ed bvJP <br /> PUMP INSTALLATION: Contractor ' r <br /> Type of Pump u qua �g �a,•, ems► r�C� <br /> r H.P. <br /> PUMP REPLACEMENT: <br /> Q State Work Done :r <br /> PUMP REPAIR <br /> OS tate Work Done r <br /> DE"STRUCTIOfV OF-WEL"L-: - wed j�DTameter � = - <br /> Describ <br /> --App�rox�imate--Depth� _ <br /> Mate ria , and, Procedure. t <br /> I hereby certify that-I-have prepared this-application and_thatLth'e wo-r01wi7,l-»be done in-accordance'! <br /> Vith San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San "Joaquin Local ` <br /> iealth 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 /> WILL LL FORA GROUT NSPECT ON PRIOR TO GROUTING AND A FINAL INSPECTION. � <br /> IGNED <br /> TITLE: <br /> DR W PLOT <br /> PLVN ON REVERSE IDE <br /> HASE I 4 1 FOR DEPARTMENT US ON Y <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: `� DATE a C� <br /> PHASE II GROUT INSPECTION PHASE I I INA INSPEClI;ON <br /> YSPECTION BY DATE , "``tr INSPECTION BY DATE <br /> i 1426 Rev, -77 <br />