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SAN JOAQUIN LOCAL HEALTH DISTRICT =Issue= <br /> 1601 E. Hazelton Ave. . Stockton, CA 95.05Telephone: (209) 466-6781 <br /> 1 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ares 1 Year From Datc: Issued <br /> _omp ete In rip tate <br />;,lir_ation is hereby made to the San Joaquin Local Health District for a permit to construct <br /> install the work herein described. This application is made in compliance with San <br /> County ''reinance '.u. 1862 and the Rules and Regulations of the San Joaquin Local Health ` <br />-r T STREET ADDRESS ,1 �f .Y / S� D L/lL.� �s�--- CITY/TOWN L�i�/��D <br /> .•-- <br /> Per's Namei i �F1�.,tr� a r-C Phone 3' <br /> �,�► ,�_ <br /> Ci ty <br /> Jress�„�'o? G 1 Phone lyis/ <br /> y / 23 <br /> ntractor's Name Licensed <br /> 'ERTIFICATE OF WOR111ANIS C0111PE11SATI01i I1,1SURANCE ON FILE WITH SJLHD? YES NO - <br />'PE OF WORK (Check): NEW WELL(C!Y'DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER Q <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0 PUMP REPLACEIiENT p 9-1 <br />[STANCE TO NEAREST: SEPTIC TANKV SEWER LINES PIT PRIVY _ (?` <br /> SEWAGE DISP�SAL MELD !,E CbL/SEEPAGE TIS OTHER � <br /> PROPERTY LINE - PRIVA E DOMiESTIC WELL PUBLT'CWESTIC GI`CL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS GA <br /> Industrial Cable Too Dia. of We xcavat on <br /> domestic/private Drilled Dia. of Well Casing, <br /> Domestic/public ----briven Gauge of Casing <br /> .r--irrigation Gravel Pack Depth of Grout ea <br /> —Cathodic Protection e/Rmtary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instar <br /> UMP INSTALLATION: Contractor H <br /> Type of Pump - <br />'UMP REPLACEMENT: [❑State Work Done -- <br />'UMP REPAIR: ❑State Work Done <br />,ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mater a an rote ure <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br /> rith 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 /> WILL CALL FDR A GROUT INSPECTION PRIO 0 GROUTING AN-OPD A FI�1AL INSPECTION. <br /> .� TITLE: 0 <br /> DATE:_27&O� <br /> ON REVE _ <br /> == --- FOR6 tTMENTZS +_ <br />',iASE I DATE 7-/� <br />—r,.TMION ACCEP-0 By <br /> 11 ZONAL COMMEN-S: PHASE III FINAL INSPECTION <br /> PHASE 1 L' N I N — <br /> '�S�'ECTIO'� BY DATE_ INSPECTION BY DATE <br /> 1178 2M <br /> 1426 Rev. 12-77 <br />