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f SAN JOAQUIN LOCAL,,HEALTH DISTRICT <br /> EFIGE USE: 1601 E. Hazelton Ave. , Stockton, CA .,95205 Permit No. 7 - ZZZ <br />` Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> fi This Permit Expires 1 Year From Date 'Issued <br /> Complete In Triplicate) ' <br /> Applicatj'on 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. <br /> EXACT STREET ADDRESS I I 4� CITY/TOWN <br /> Owner's Name JO Phone <br /> r Address ^ Ci ty.. cx- ' <br /> Contractor's Name -� License# G 11 1 Phone '3 C k-[:11� <br /> IS CERTIFICATE OF WORKMAN'S CO"PENSATIO`1 INSURANCE ON FILE. WITH SJLHD? YES 110 <br /> TYPE OF WORK (;Check) : NEW WELL W ,DEEPEN Q RECONDITION DESTRUCTION( <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT EJ � <br /> +f DISTANCE TO NEAREST: SEPTIC TANK 7-� , SEWER LINESS ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 9 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELL s <br /> INTENDED USE �' TYPE OF WELL : CONSTRUCTION SPECIFICATIONS"•,' <br /> Industrial Cable Tool - Dia. of Well Excavation_ p <br /> Domestic/private Drilled d Dia. of Well Casing f <br /> Domestic/public Driven Gauge ofiCasing <br /> I rri gati onGravel Pack Depth of,-Grout -Sear µ� <br /> Cathodic Protection _�Rotary Type of Grout <br /> Disposal Other 'Other Information <br /> Geophysical . Surface Seal Installed b <br /> PUMP INSTALLAT=ION: Contractor H.P. <br /> 5 Type of Pump <br /> PUMP REPLACEMENT: Q State Work Dane i <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION ON WELL: Well Diameter Approximate Depth <br /> Descrioe Material an2 Procedure l` <br /> F f' <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordinances , State Laws , and Rules andlRegulations of the San Joaquin Local <br /> Health -D-i-st-ri ct. --Homeowner--o-.r l-i-cens-ed -agent'-s--s-i-gnature cer'ti fi es the fol owi ng-: <br /> I certify that in the performance of the work for which this permit is issued, I shall <br /> "I <br /> employ- any person in such manner as to become subject to Workman 's Compensation <br /> F laws of California." y <br /> f I WILL CALkJORAA GROUT INSPECT - PRIOR TO GROUTING AND .A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> R W PLOT PLTN ON REVERSE §IDD <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IDATE ��1�' <br /> APPLICATION ACCEPTED BY -- o <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION. <br /> INSPECTION BY DATE �.. INSPECTION BY DATE / 1 <br /> Cu ,A9G o,,,,,. ., -��. /78 . 2M <br />