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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 -E. Hazelton Ave. , _Stockton, CA 95205 Permit No. - d <br /> Telephone: (209) 966-6781 <br /> Date Issued1-71 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT a <br /> Thlis Permit. Ex ires 1 Year From Date Issued <br /> f 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 the Rules and Regulations of the San Joaquin. Local ..Health <br /> District. <br /> EXACT STREET ADDRESS , Ch1 CITY/TOWN 1Jot3 <br /> Owner's Name Zd-S Phone <br /> Address- City /w0� <br /> Contractor' s Name &L,L 1 FI,C .)4-y- Li cense#3y770, 7,Phone_3/ In� <br /> IS CERTIFICATE OF WORKMANIS COMPENSATION! INSURAINCE ON FILE WITH SJLHD? YES NO <br />, TYPE -OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ® DESTRUCTION <br /> WELL CHLORINATION Q WELL ABANDONMENT a OTHER ( .0 <br /> PUMP INSTALLATION 0 PUMP REPAIRE3 PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC' TANKBV-f-SEWER LINES A(4- PIT PRIVYkA <br /> SEWAGEI. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER. N. <br /> PROPERTY LINE -, PRIVATE E DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation12 <br /> . <br /> Domenic/privateDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ]WO—PVC. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary - Type of Grout i <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: t <br /> ::., <br /> PUMP INSTALLATION: Contractor : <br /> Type of Pump H.P. .1 <br /> PUMP REPLACEMENT: ❑ State Work Done `;>1 <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe MateHal and Procedure :r <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 LocaVl <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. " F <br /> I WILL CA F A OUT. I ECTION PRIOR TO GROUTING AND A FINAL INSPECTION. !E <br /> SIGNED ! TITLE: DATE: ' <br /> N <br /> (DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />.PHASE I <br /> APPLICATION ACCEPTED BY DATE_7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _Z,'.2,77,K <br />