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40" SAN JOAQUI.N LOCAL HEALTH DISTRICT <br /> �rICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued G <br /> This Permit -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 described. This application is made' in compliance with San <br /> ,'oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name T6 kt, Phone <br /> Address , A _ City ' <br /> Contractor' s Name + License# _G_ 37z��hone y ZZ <br /> IS CERTIFICATE OF WORKHAN'S Mi ENSATIOE! IIISORANC't ON FILE WITH SJLHD? YES td0 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN a RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION C7 PUMP REPAIR M PUMP REPLACEMENT ❑ N <br /> DISTANCE TO NEAREST: : SEPTIC TANK SEWER LINES PIT PRIVY <br /> .. , SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> Y PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial' Cable Tool Dia. of Well Excavation <br /> �c _Domestic/ ' <br /> rivateDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of -Grout <br /> Disposal Other Other Information ` <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: z Contractors <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: CRState Work. Done <br /> OF-WELL-,:DESTRUCTION OFKWEL : -Well- Diameter ._' �� _ ApproximatefDepth <br /> Describe Materia an Procedure <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 Workman's Compensation <br /> laws of California." <br />'. I WILL CALL, FOR A GROUT INSPEC RI-0 TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ITLE: f. DATE: <br /> RAW PLOT PL`AN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE -� <br /> ADDITIONAL COMMENTS: &I , <br /> P II UT INSPECTION PH _IJJ­ FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE 'l <br /> EH 1426 Rev.`12-7.7 rel 1 /7�P 2M <br />