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' JOAQUIN LOCAL HEALIH UIJIKIL - <br /> FOR OFFICE USE: 1601 Hazelton Ave. , Stockton, CA ti, 05 Permit No.Tg-�3�3 <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issuedj/_��9_� I <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <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 /> ,Oarl;tin County Ordinance P;u . 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Distr ct. <br /> EXACT STREET ADQRESS � �' �' <br /> f� �� , � i�1 CITY/TOWiV� �II <br /> Owner' s Name . 1 ' Phone_ <br /> Address _ City <br /> —fi <br /> Contractor' s Name % ­) P14� l t,1_1 i ,T:, r LicensePhone /- 1 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSUR NCC ON FILE WITH SJLHD? YES Imo ' NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN O RECONDITION [7 DESTRUCTION❑ C,IIN <br /> WELL CHLORINATION 0 WELL ABANDONMENT Cj OTHERf_=1 - A <br /> PUMP INSTALLATION p----T�UMP REPAIR 0 PUMP REPLACEMENT p � <br /> DISTANCE TO NEAREST: SEPTIC TANK,�(7li SEWER LINES,L I�PIT PRIVY <br /> SEWAGE DISPOS . FIELD CESSPOOL/SEF E PIT-�,� �OM),/OTHER_ " / <br /> PROPERTY LIND 1PRIVATE DOMESTIC WELL PUBLIC DESTIC WELT_ C� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial -Cole Tool Dia. of Well Excavation / _i7ii - <br /> Domestic/private gilled Dia. of Well Casing <br /> — Domestic/public Driven <br /> Gauge of Casing— <br /> Irrigation 'ravel <br /> asingIrrigationGravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout C c�Lc'tt <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: 5 <br /> PUMP INSTALLATION: Contractor 11-lo or'Nl1s %� % •� lrt�-- <br /> Type of Pump <-'' H.P. -; <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ` Decri be Material and Procedure <br /> I hereby certify that I h ve prepared this application and that the work will be done in accordanc <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 /> laws of California." <br /> I WILL CALL FOR A U - INSPECTION PRIOR TO GROUTING AND A FI AL INSPECT ON. <br /> SIGNED `/ ( y. ,j' TITLE: DATE: <br /> DRAW PLOT PL N ON REVERSE- SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY Z, DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY �� DATE INSPECTIOI V, N BY - DATE <br /> EH 1426 Rav 19-77 <br />