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�iSAN <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No 7T /573,0 <br /> II Telephone: (209) 466-6781 <br /> j Date Issued/o ,2_>K <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This'lPermit Ex ires' l Year. From Date .Issued <br /> Complete In Trip icate ' <br /> Application is hereby made to the San Joaquin Local Health District for a -permit to construct <br /> and/or install the work herein eescribed. This application is made in compliance with San <br /> 2oaQu n County Ordinance ,�No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> str�:Ct' <br /> EXACT STREET ADDRESS ..� � . °CeJ," CITY/TOWN <br /> Dwner's Name �'�p Phone <br /> Address 6,-)f City <br /> Contractor' s Name �� �� License# Phone_�3� <br /> IS CERTIFICATE OF WORKMAN'S COMI: ENSATIQN INSURANCE ON FILE WITH SJLHD? YES 'NO <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN ❑ RECONDITION Q DESTRUCTION[� <br /> WELL CHLORINATION 0 WELL ABANDONMENTED OTHER 0 <br /> PUMP INSTALLATION C PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT-,PA-IVY off-, <br /> SEWAGE DiiSPOSAL FIELD CESSPOOL/S�EWE PIT OTHER d <br /> PROPERTY]ILINE -. PRIVATE DOMESTIC WELL J PUBLIC DOMESTIC WELL <br /> INTENDED USE + TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial :, Cable Tool Dia. of Well Excavation <br /> Domestic/private 11I Drilled Dia. of Welll.Casing <br /> Domestic/public Ail Driven Gauge of Xas.i ng <br /> Irrigation If' Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1!1I Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical 'Surfa-ce Spa] Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work ane <br /> PUMP• REPAIR: . Q State Work Done <br />)ESTRUCTION OF WELL: Well--- Diameter :_, Appr6ximate Depth <br /> Describ6lMaterial and Procedure., . <br /> I hereby certify that I have prepared this application and 'that the work will be done in accordance <br /> Frith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> lealth District. Home owner oijj`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 C R A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE �� TITLE: DATE: <br /> SII DR W PLOT PLN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 1HASE I I� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION pHA III FLVL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DAT li <br />�N'1.426 Pau 17,a;,77 - "' 1 /7A 7M r <br />