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SAN JOAQUIN;'LOCAL HEALTH DISTRICT <br />{ FFIC£ USE: 1601 Hazelton Ave:; Stockton, CA Permit <br /> `'Telephone (209) 466=678I _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3/3,- � <br /> Thi s.:Perm t..Ex ixes .1 .Year..FroT, Date:, Iss.ued . <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District fora -permit to ;'construct <br /> and/ori`ns`tal 1 'the work heroin described. 'Thi,s appl nation is made in compliance with- San <br /> J,oan,-in County"Ordinance No: 1862 and the Rules and Regulations of the San Joaquin-Local Health <br /> District <br /> EXACT. STREET Afl :SS :..,. :: . ;, ,. : , _ CITY/TORN <br /> Owner' s Name Phone <br /> Address- <br /> Contractor's <br /> ddressContractor s Name License#)�'`373 Phone 4 �7c*� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO-N INSURANCE ON FILE WITH SJLHD? YES v NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION[2 �� � <br /> WELL CHLORINATION a WELL ABANDONMENT ❑ OTHER <br /> w PUMP INSTALLATION ❑ PUMP REPAIR 0 PUMP REPLACE NT <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing ` <br /> Domestic/public Driven Gauge of Casing <br /> 4 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> 4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />, PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: [aSltate Work Do I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> k Describe Material an2 Procedure <br /> 0 hereby certify that I have prepared this application and that the work will be done in accordant <br /> Ivith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> lealth 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 /> i iIGNED TITLE: DATE: 1,9--22 <br /> (DRAW PLOT PLAN ON REVERSE IDE <br /> CHASE 'I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> a <br />