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,., AN JOAQUIN LOCAL HEALTH DISTRI�,,,� OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. i.E _, Telephone: (209) 466-6781 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -� This Permit Expires 1 Year From Date Issued Complete In Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health bistrict. EXACT STREET ADDRESS / Yu / /✓ �( iti. CITY/TOWN . wner's Name 'P@ etom`�,, , 4-„ Phone Address / 2 �aF / n/ SL�cYc ane - City Gr` `ontractor's Name�� ,, �_. , License# /=1 -Phone IS CERTIFICATE OF WORKMAN'S COMPENSA IO'; INSURANCE ON FILE WITH SJLHD'. YES NO . YPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION[j WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 � - PUMP INSTALLATION ❑ PUMP REPAIR® PUMP REPLACEMENT ❑ `N ra t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY a SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p .. PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL C INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Industrial Cable Tool Dia. of Well Excavation Domestic/private Drilled Dia. of Well Casing Domestic/public Driven Gauge of Casing X Irrigation Gravel Pack Depth of Grout Seal Cathodic Protection Rotary Type of Grout '— Disposal Other Other Information Geophysical Surface Seal Installed by: UMP INSTALLATION: Contractor / Type of Pump 1 H.P. zu -UMP REPLACEMENT: ❑ State Work Done 'cUMP REPAIR: ©State Work Done el.f r s y c ><v 30H-a> d .T.r,-J, / nESTRUCTION OF WELL: Well Diameter Approximate Depth _ Describe Material and Procedure hereby certify that I have prepared this application and that the work will be done in accordant ith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca- Realth District. Home owner or licensed agent' s signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." I WILL CALL FOR A GROUT INSPECTION PRIOR_ TO GROUTING AND A FINAL INSPECTION. IGNED ITLE: DATE: C ORAW PLOT PLAN ON REVERSE SIDE J FOR DEPARTMENT USE ONLY HASE I RPPLICATION ACCEPTED BY \LNJL{14z ns DATE ODITIONAL COMMENTS : PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION — 'ECTION BY DATE INSPECTION BY ATE _ d;