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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />=fOROFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ii-� <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 /> Joaquin'- County Ordinance No. 1862 and t e Rules and Regulations of the San Joaquin Local Health <br /> 'district. <br /> EXACT STREET ADDRE S �� Z(J CITY/TOWN <br /> -Zaroe <br /> Owner's Name Phone <br /> Address /Z,; City. <br /> Contractor's Name License# Phone- <br /> I IS CERTIFICATE OF WORKMAN'S CO"tPENSATIO"! I'NSURAINCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL O DEEPEN ❑ RECONDITION [❑ DESTRUCTION <br /> WELL CHLORINATION Q WELL ABANDONMENT ® OTHER�' V� <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br />-, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY_ { <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. RRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. <br /> Industrial Cable Tool Dia. of Well Excavation k <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of" Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed by: ! <br /> PUMP INSTALLATION: ..-. Contractor 67' L� <br /> Type ofPump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done + <br /> DESTRUCTION OF WELL: Well Diameter Approximate Approximate Depth <br /> Describe Materia and -Procedure ` <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 OUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:: ` <br /> DRAW PLOT PL N ON REVERSE SID <br />� <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �) 9 „ a i _ _ DATE: — —7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY p�(/j�//►//(/p+ DATE RAPE BY C DATE q, /If 17 <br /> C.���y <br />