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FFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit toconstructand/or install the work herein described. This application is made in compliance with San ' <br /> Joaquin County Ordinance No. 1862 and the Rules and- Regulations of <br /> District. F,,. the San Joaquin Local Health <br /> EXACT STREET ADDRESS 9�a e,• `/ <br /> 7 C G� C I TY/TOWN S 76/c«�i <br /> Owner's Name c�� t_ <br /> Address 73'00' �� W)Ar Phone 95 7 - :3 i <br /> Contractor's Name r. N ( CAcae.tC City S�-o r ecTr7 r <br /> �,.�,� : A � � „ � License# <br /> Phone rk v14 <br /> IS. CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES <br /> TYRE OF WORK (Check) : NEW WELL L DEEPEN 0 RECONDITION ❑ DESTRUCTION N <br /> WELL CHLORINATION Q WELL ABANDONMENTX OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR Q" PUMP REPLACEMENT [J <br /> DISTANCE TO NEAREST: SEPTIC TANK J®o6' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE -P-Ir— OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WEL <br /> INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable To Dia. of We 1 Excavation <br /> .�____�Domestic/private Drilled Dia. of Well Casing <br /> _Domestic/public Driven <br /> ___,____Cathodic Protection Irrigation =Rotary Gravel Pack Depth of Groute of Sea <br /> _Disposal ether Type of Grout <br /> -_Geophysical Other Information <br /> PUMP INSTALLATION: Contractor Surface Seal Insta ed Dy: <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> ES`C�TRU�CTI ON OF WELL: Well Diameter 12 `` <br /> Describe Materia an Procedure �� Approximate Depth o� < <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 Loca <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 />[_ WILL CALL FOR A GR LST INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />;IGNED <br /> TITLE: C>L -7DATE: }� `( <br /> DR P T N ON REVERSE IDE^ <br />'HASE IR DEPARTMENT USE ONLY <br /> TPP LICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> NSPECTION BY PHASE ITI FINAL INSPECTION <br /> DATE <br />'1 14 26 Rev. 9/7g INSPECTION BY i[3? DATE � <br /> __ <br /> 0/7Q e►a <br />