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N JOAQUIN LOCAL HEALTH DISTRIC <br /> FFICE USE: 16014! Hazelton Ave. , Stockton, CA `rJZ05 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date IssuedC <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 /> in`d/or install the work herein described. This application is made in compliance with San <br /> 'naauin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> i >trict. <br /> XACT STREET ADDRESS 340 6 S • W J CITY/TOWN �Ty <br /> 1 ier's Name '1$ .SYO Q /' Phone 40-393/ <br /> ,tMress P 0 . 13d X /O- city L <br /> itractor' s Name GL-AAA- We,CL FZ—ft/A. Cp, J..Z-License# 7602- Phone 2-,,l <br /> "S CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> 'E OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> - WELL CHLORINATION 0 WELL ABANDONMENT O OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR p PUMP REPLACEMENT 0 <br /> ;TANCE TO NEAREST: SEPTIC TANK AZ -SEWER LINES+1O _SPIT PRIVY <br /> SEWAGE DISPOSAL FIELW/W / CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LI 600RIVATE DOMESTIC WELL'EL0> _ 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 /> Irrigationyn vel Pack Depth of. Grout Sealy-CAi 0 V C <br /> _Cathodic Protection Rotary Type of Grout 13EAJ1'4,%JJ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> 114P INSTALLATION: Contractor <br /> _ Type of Pump H.P. <br /> UMP REPLACEMENT: 0 State Work Done <br /> 11P REPAIR: ❑State Work Done <br /> nTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> niereby certify that I have prepared this application and that the work will be done in accordan< <br /> *h San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca'. <br /> lth 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 /> —ILL CALL FORA GROUT I S EC ION PRIOR TO ROUTING AND A FINAL INSPECTION. <br /> If,N . TITLE: DATE: %-f- 7 � <br /> DRAW PLOZfLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> SASE I <br /> LIGATION ACCEPTED BY�Vpyno, __ DATE <br /> feITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> i ?ECTION BY DATE �- n 9 INSPECTION BY (tic DATE $- -F0 <br /> 1AOc n— In 11 11n mr <br />