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6 <br /> SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> 0 F'Iff-�USE: 1601 E. Hazelton :Ave. , Stockton, CA 95205 Permit No. <br /> :1194 <br /> 1d Telephone:, (209-Y-46-6'-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP 'PERMIT Date Issued 7-/171-',7 <br /> j Th,is .Permit Ex ires I Year From Date Issued <br /> t Complete, In Triplicate ; <br /> Application is hereby made to. the San Joaquin Local,-Health. i <br /> and/or' ; , q District for a permit to construct <br /> nstall the work herein described. This application is made in compliance with San <br /> .'oanuguons of -the San Joaquin Local <br /> in County �Ordinance 11 1862 and the Rules and Regulations Health <br />( District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name ~ _4 <br /> Phone <br /> Address City <br /> Contractor' s Name License# __ hone y <br /> IS CERTIFICATE OF WORKMIVCM rIJSATT ON INSURA CE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN Q� RECONDITION ❑ DESTRUCTION[j <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER F-3 <br /> PUMP INSTALLATION N PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAG- <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC-DOMESTICRWELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />�IndustriaT Cable Tool Dia. of Well Excavation <br /> �Domestic/public <br /> omestic/private DrilledDia. of Well Casing(-Driven - Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection j Rotar <br /> Disposal y Type of Grout <br /> 1 Other Other Information; <br /> Geophysical I Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump +� <br /> W.P. <br /> PUMP REPLACEMENT: <br /> []State Work Done <br /> PUMP RCM;M <br /> State Work-Done � W# <br /> DESTRUCTION OF WELL: Well Diameter �- <br /> Describe ia a- <br /> Matern Procedure Approximate Depth <br /> 1 <br /> I hereby certify that I have prepared this application and that the work will 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 sdch manner as to become subject to Workman 's Compensation <br /> laws of California. " <br /> WILL CALL FORA GROUT INSPECT,I4A1 P Q:R GROUTING AND A FINAL INSPECTION. <br /> SIGNED - `" DATE: �! <br /> D, PLOT PL N REVERSE SIDE f <br />' <br /> ' FOR DEP RTMENT USE ONL <br /> WASE IY <br /> PPLICATION ACCEPTED BY. DATE Y 7� <br /> DDITIONAL COMMENTS: <br /> PHASE II GRO INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION 8Y ATE INSPECTION BY 4 TE <br /> 11426` Rev: 12=77 <br />