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I w SAN JOAQUIN ,LOCAL HEALTH DISTRICT <br /> FFI,OE USE: 1601 E. Hazel tori Ave. , Stockton, CA 95205 FDate <br /> t No. <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Issued <br /> This Permit Expires 'I Year From Date Issued 319", -L - f <br /> Complete In Triplicate -f <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct' " ^ <br /> and/or install the work herein described. . This application is made in compliance wi=th San. <br /> ,'oaquin County Ordinance _No. 1862 .and. the Rules and Regulations of the. San Joaquin Local Health <br />� 'J'StriCt. (3aoo �_ g, <br /> EXACT STREET ADDRESS ° <br /> Owner's Name <br /> r, , <br /> Phone . <br /> Address CityAy, <br /> Contractor' s Name �- License#. Phone — <br /> 'S CERTIFICATE OF WORKMIAMI'S CO"IPENSATIOIN ' INSURA"IC ON FILE'WITH SJLHD? YES y ;VO <br /> TYPErvOF .WORK (Check} :� NEW—W ( D--EEPEN pRECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 <br /> h PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT❑ <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES 1��,i PIT PRIVY _ 4 <br /> SEWAGE DIS 0 AL-4�L�fIELD f CESSPOOL/SE PAGE PIT —.OTHER— <br /> 'a ~ <br /> PROPERTY LINE/ �iPRIVA RESTIC WELL� PUBLIC—DOMESTICWELL <br /> INTENDED USE TYPE OF W �ELL CONSTRUCTION SPECIFICATIONS d `' <br /> Industrial Cable Tool Dia. of Well Excavation -11^ <br /> Domestic/private Drilled Dia. of Well Casing +� + <br /> Domestic/public Driven Gauge of Casing wE <br /> Irrigation Gravel Pack Depth of Grout Seal + <br /> Cathodic Protection Rotary . Type of Grout <br /> Disposal Other <br /> Other Information <br /> Geophysical <br /> Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump / ell <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> � 1 <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <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 and Regulations of the San Joaquin Local <br /> Health 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 /> Taws of California. " <br /> I WILL CALL FOR A G OUT NS E ION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE: -�-� DATE: � <br /> DR W PL L N ON REVERS SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY 4 <br /> � <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE ,2 S-A� <br /> PHASE I GROU , INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE j2--Z — � INSPECTION BY DATE9/ <br /> 71 <br />