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SAN JOAQUIN LOCALFHEALTH DISTRICT <br /> FOR <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. _ 5 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued y�/.� - <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 Sari <br /> loanuin County Ordinance No. 1862 and the Rules and Regulations of the San. Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ` CITY/TOW <br /> Owner's Nam Ge& <br /> y' C i tyL <br /> Address73 <br /> Contractor's Name U �� Licensehone#/&"2*3 <br /> IS CERTIFICATE O�,WORKMAH-S COMP£NSAT.I-0"1 INSURANCE ON FILE WITH SJLHD? YES NO <br />' TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ W,, °! <br /> WELL CHLORINATION ❑ WELL ABANDONMEN1 -q OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REP IRj& PUMP REPLACEMENT E] W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> E PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL -4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation s <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 d Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> 4 <br /> Type of Pump �_-- _ _. H.P. <br /> PUMP REPLACEMENT: [] State WorkD ne ~�~` <br /> PUMP REPAIR: State Work Don <br /> DESTRUCTION OF WELL: Well Di�meter N Approximate Depth <br /> Describe\-Material andProcedure <br /> I hereby certify that I have prepared this appl ��cati o'n--a-nd--tha-t-the-work-wi-1`l—"b—e done in accordanc <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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> ISIGNED TITLE: DATE: <br /> DR W PPLOT PLAN ON -REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> �PHASE I <br /> ' APPLICATION ACCEPTED BY DATE414 <br /> S <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT . INSPECTION PHASE II-I FINAL INSPECTION <br /> INSPECTION BY DATE " INSPECTION BY /p�`/`G9 ____ DATE <br /> .. � .-T8' _2M <br />