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~�FFICE USE: <br />r"';N JOAQUIN LOCAL HEALTH DISTRICT <br />1601 � Hazelton Ave. , Stockton, CA '_.205 <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br />(Complete In Triplicate) <br />Permit No. 2- <br />Date Issued 2 -a -5 - <br />Application is hereby made to the San Joaqu'in'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 />JoaquiA County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br />District. <br />EXACT STREET ADDRESS'd 7.w <br />CITY/TOWN-=- <br />Owner's Name �,�y C�.yG-��L� `� � Phone � 3 �`�= G 7 <br />Address d City- T <br />Contractor's Name License )_3 7phone 3- <br />IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAMCE ON FILE WITH SJLHD? YES_ �NO <br />TYPE OF WORK (Check): ANEW WELL DEEPEN ❑ RECONDITION d DESTRUCTION <br />WELD CHLORINATION ❑ - WELL ABANDONMENT Q OTHER 0 � <br />PUMP INSTALLATION EN . PUMP REPAIR ❑ PUMP REPLACEMENT [] <br />DISTANCE TO NEAREST: SEPTIC TANK 7-�" SEWER LINES 7S' PIT PRIVY <br />SEWAGE DISPOSAL FIELD loo f CESSPOOL/SEEPAGE PIT OTHER <br />PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />' Industrial <br />Cabe Tool Dia. of We ] Excavation / e <br />X Domestic/private Drilled Dia. of Well Casing <br />Domestic/public Driven Gauge of Casing <br />Irrigation -,e Gravel Pack Depth of Grout Seal - <br />Cathodic Protection _Rotary Type of Grout <br />'Disposal Other Other Information <br />Geophysical Surface Seal Insta ed <br />PUMP INSTALLATION: Contractor 1�] <br />Type of Pump n <br />PUMP REPLACEMENT: <br />PUMP REPAIR: <br />DESTRUCTION OF WELL: <br />�] State Work Done <br />❑ State Work Done <br />Well Diameter Approximate Depth <br />Describe Material and Procedure <br />I hereby certify that'I.have prepared this application and that the work will be done in accordant, <br />Kith 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 />C WILL CAL FO A GROUT LNSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />;IGNED <br />TITLE: <br />ON REV <br />DATE:`7' <br />'RASE I "" i"-nr♦ I I If lI U3C VIYL 1 <br />,PPLICATION ACCEPTED BY .' DATE ] 3 <br />IDDITIONAL COMMFNTS: <br />PHASE II GROUT INSPECTION <br />NSPECTION BY DATE <br />U 1 A -14' <br />PHASE III FINAL INSPECTION <br />INSPECTION 8Y C .�,,,, DATE <br />��--- <br />