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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1FICE USE: f 1601 E. Hazeltan.,Ave: ; Stockton, CA —95205 Permit No. Z <br /> Telephone: , (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued s I� <br /> This Permit Expires 1 Year From:Date . Iss%ed. <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 OrdinancelNo. 1862 and the Rules and Regulations of the San Joaquin Local- Health <br />'district. <br /> EXACT STREET ADDRESS7� CITY/TOWN <br /> Owner's Name. GG'I !2C Phone <br /> Address. I. I Y'1! City <br /> Contractor's Name 1 S'�yl License` 0��'hone -� <br /> �M cl -1 <br /> IS CERTIFICATE OF WORKMAN'S COfmPENSATIO"1 INSURANCE ON FILE WITt-1 SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN4a- RECONDITION ® DESTRUCTION[] W <br /> WELL CHLORINATION D WELL ABANDONMENT•0 OTHER 0 , <br /> PUMP INSTALLATION CI PUMP REPAIR 0 PUMP REPLACEMENT El <br /> I, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 3 <br /> INTENDED USE i� TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ` Cable Taol Dia. of Well Excavation ; <br /> </Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public ' I Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal i' Other Other Information <br /> Geophysical 1 Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of, Pump —�H.P. , <br /> PUMP. REPLACEMENT: Q State Work Done n <br /> i� <br /> PUMP REPAIR: p State Work Do.ne,_.�, <br /> DESTRUCTION °OF WELL: Well Diameter Approximate Depth. <br /> Describe Material and Proce urea.. <br /> I hereby certify that I have prepared this application and that the work will be done in accordancd <br /> with San Joaquin County Ordinances , State Laws , and4R61es 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 •thi-s­permit-is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> CP <br /> laws of California.",l <br /> I WILL CALL FOR AOUT :INSP CTION PRIOR TO GROUTING�AN6 A FINAL INSPECTION. ;7r' <br /> SIGNED TITLE: /1 4Y ri— DATE: <br /> ifDRAW PLT PLAN' ON REVERSE SIDE 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION- ACCEPTED BY/4, ' DATE -f=7&, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEJJI, FWL INSPECTION <br /> INSPECTION BY I `- DATE �. INSPECTION BY .DATE ;Z 7 <br />