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FF2CE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, CA '95205 Permit No. ?9- <br /> Telephone: (209 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7-/4-25 <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 San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. O _ <br /> EXACT STREET ADDR - <br /> T7 CITY/TOWN''%'. <br /> Owners Name C"'r , Phone <br /> Address 01r ( <br /> Contractor's Name � ,,., . . tL,2 J/ �� License? ws%"7 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSU�tAMlCE ON FILE WITH SJLHD? YES k NO <br /> TYPE OF WORK (Check) : NEW WELL,0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT O OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANKA i,. SEWER LINES —•- PIT PRIVY— <br /> SEWAGE DISP S. L IELQ,/r� � 'i CESS OL/SEEPAGE PTT—�.. OTHER" <br /> PROPERTY LINE * PRIVA E MES TIC WELL` PUBLIC D ESTIC W€C:_ Q*' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> In ustria Cable Tpol Dia. of We Excavation <br /> _Domestic/private <br /> Domestic/public Drilled Dia. of Well Casing. �, r <br /> P Driven Gauge of Casing, <br /> Irrigation _Gravel Pack Depth of Grout Seal , , r <br /> Cathodic Protection Rotary Type of Grout��� <br /> Disposal Other Other Informat <br /> Geophysical Surface Seal Installed v: <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump H <br /> 'UMP REPLACEMENT: CIState Work Done <br /> 'UMP REPAIR: ❑State Work Done <br /> )ESTRUCTION OF WELL: Well Diameter Approximate Depth ` <br /> Describe Material an Proce ure <br /> c <br /> hereby certify that I have prepared this application and that the work will be done in accorda <br /> lith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin toc <br /> °ealth 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. <br /> IGNED '` f <br /> '- TITLE: - ••L DATE:Z I11—b 77 <br /> ON REV <br /> 1ASE IFOR DEPA T N 1 1111111E/ ,N <br /> *9] <br /> 'P-L1- ION ACCEPTED BY ��.•, ? ,I'`� � � /// s '- <br /> DATE___ <br /> )DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ISPECTION BY' nATr _____ <br />