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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> --- � Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /6_�g <br /> This Permit Expires 1, Year From Date Issued <br /> p (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 /> Joaquin County Ordinance No. 1862 and th9J,&r),(ps`and Regulations of the San Joaquin Local Health <br /> District. /lAwel .41v Vd Num Ujs <br /> EXACT STREET ADDRESS /-/D iAV xr CITY/TOWN ,L <br /> Owner's NameTp Phone_369 g/Zy <br /> Address `�� <br /> (1 .IF NF G C i ty__ Gam/ <br /> Contractor' s Name / J1 6 /, License Phone <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATIO�J INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN �Y RECONDITION ❑ DESTRUCTION d w <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER n c <br /> PUMP INSTALLATION [] PUMP REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL Z-0-0— PUBLIC DOMESTIC WELL -� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION 'SPECIFICATIONS CS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia.' of Well Casing_ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout S <br /> Cathodic Protection Rotary Type of Grout o <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Inst---fid b <br /> PUMP INSTALLATION: Contractor Gin ,.� <br /> Type of Pump ov H.P. / <br /> PUMP REPLACEMENT: F]State Work- Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter zQ3 Approximate Depth ZZ2 ' <br /> Describe Material ancr ro�P ce2ure " <br /> Al <br /> N* <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 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 WDrkman's Compensation <br /> laws of California." <br /> I WILL CALL F R A GROUT- 1 PE TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DRAW PLOT PLAINT ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY , >. DATE 3 v3 <br /> EH 142_6 - Rev_ 12-77 1 /7A 9M <br />