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S JOAQUIN LOCAL HEALTH DISTRICTS <br /> �-R­OFFICE USE: 1,601 L ,hazel ton Ave. , iS.tockton, CA 9; 15 Permit No. 7 :i-:L�� 1 <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 4 -7 -7 <br /> f <br /> This Permit Ex fres 1 Year From Date Issued <br /> Complete In Triplicate , <br /> lication is hereby made to the San Joaquin- Local Health District for a permit to construct <br /> /or 4nstall the work herein described. This application is made in compliance with San <br /> *juin County Ordinance No. 1862 and the Rules. and Regulations of the San Joaquin Local Health <br /> trict. <br /> CT STREET ADDRESS ®. ,rtw' CITY/TOWN A1AA1 <br /> :er's Name 5 L , Phone -5 <br /> City J. <br /> itractor's Name kS License -3W 7- - Phone . V <br /> CERTIFICATE OF WORKMAN'S CO'iPEN-SATION I!ISURA"!CE ON FILE WITH SJLHD? YES Ido <br /> 'E OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT EJ OTHER ❑ P.- — <br /> PUMP INSTALLATION 5Z PUMP REPAIR❑ PUMP REPLACEMENfnVft0 i <br /> ;TANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER a' <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 /> 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: I <br /> IP INSTALLATION: Contractor �- <br /> Type of PumpItja H.P. <br /> 1P REPLACEMENT: [] State Work Done <br /> AP REPAIR: O State Work Done <br /> STRUCTION OF WELL: Well Diameter Approximate Depth i <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordancEy <br /> th San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local $ <br /> alth 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 /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. �y <br /> GNED TITLE: DATE: <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR D>_PARTMENT USE ONLY <br /> iASE I <br /> 'PLICATION ACCEPTED BY .- , DATE - S"- <br /> 01TIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEJJ , FINA6 INSPECTION <br /> SPECTION BY DATE ;` INSPECTION BY �',. ti!,:!.� .;, DATE / <br /> I <br />