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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: ✓ 1601 E. Hazelton Ave; , Stockton, CA 95205 Permit No.z -���� <br /> Telephoner (209) 466-6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ <br /> This Permit Expires 1 Year From .Date Issued _ . .. <br /> Compl etef In Triplicate) `s <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 /> doanuin County Ordinance "o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Di s t 1 y L 1.. <br /> EXACT STREET ADDRESS /617ITY/TOWN -- <br /> Owner' s Name Phone <br /> Address9 Y City - <br /> Contractor' s Name Licenseg f"5 Phone jj:' Zzi /.Z-2 <br /> IS CERTIFICATE OF WORKMAN-'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES 4140 <br /> TYPE OF WORK - h _ D STRUCTION � - <br /> (C.eck} : NEW WELL C�dEEPEN ❑ RECONDITION � E ❑ o , <br /> i WELL CHLORINATION WELL ABANDONMENT ❑w -OTHER F_:1 L4 i <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT p s <br /> DISTANCE+ TO NEAREST: SEPTIC TANK 0z EWER LINES PIT PRIVY <br /> SEWAGE DISP SAO L FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL fi <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial :ter — - Cable Tool Dia. of Well Excavation �„� ' o , <br /> t Bomesti c/pri vate: ._. ..... .-- Drilled Dia. of Wel-1 Casing q <br /> Domestic/public A Driven Gauge of Casing •__.__ <br /> ,Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic;Protection ___4__BG-tary Type of Grout <br /> , Disposal Other ;_ Other Information <br /> Geophysical f . Surface Seal Installed b : I <br /> PUMP INSTALLATION: Contractor <br /> Type of., Pump H.P. } <br /> 4 <br /> PUMP REPLACEMENT: C]State Work Done <br /> PUMP REPAIR: "❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> —_-Describe Material ana Procedure <br /> I hereby' certify that.,I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local ; <br /> Health Di sari ct:. -.Home owner..or-...1 i censed. agent's signature certi.fi es 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 /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED s TITLE: DATE: � z� <br /> DR W PLOT •PL N ON REVERSE SIDE) 'e <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I E �: <br /> APPLICATION ACCEPTED BY ; DATE /- 7, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE IaNSPECTION BY DATE q -7c <br /> ��ti <br />