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SAN JOAQUIN LOCAL HEALTH DISTRICT -----� <br /> FFICE USE: iR 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 -� <br /> Telephone: (209) 466-6781 �/7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> T6 s ' Permit Ex ires I Year From Date Issued <br /> Complete In Tri pl i tate <br /> Application is hereby made to -the San Joaquin Local Health District for a. permit"to construct <br /> and/or i'nstalT the work here-i.n described. This application is made in compliance. with San <br /> Joan. in County ordinance No.� 1862 and the les and Regulati ns . f he San. Joaquin, Local Health <br /> � Distr�ct. � <br /> t <br /> EXACT STREE=AR SS'tl CITY/ <br /> ; Owner' s Nam Phone <br /> Address . .. j Ci ty <br /> Licens Phone_4.g7!�� <br /> Contractor's Name --- <br /> 4IS CERTIFICATE OF WOMIAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> _ _._ Y � _-�..-+c-=-j..�--�..��_��=-+C.:-4'.�z-__r.. ..�-_ .: ... -......r._._�.-.._ter�_.�.-.�_.__- �---✓��4� -..�-_-_s� <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN ❑ RECONDITION ❑ DESTRUCTION[2 <br /> WELL CHLORINATIONWELL ABANDONMENT ❑ • OTHER 0 <br /> N PUMP INSTALLATION El PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> ° DISTANCE TO NEAREST:! SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> id PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE• !l TYPE OF WELL . 'CONSTRUCTION SPECIFICATIONS <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 i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ' PUMP REPLACEMENT: ;, p State Work Done- <br /> , PUMP REPAIR: CKState Work Done c4- <br /> Approximate DESTRUCTION-OF -Y1Well Diameter A pp Depth <br /> Describe Material and Procedure <br /> I r <br /> I hereby certify that I have prepared this application- and that the work will be done in accordan, <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 Cal i forni af.." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: kp DATE: <br /> DRAW PLOT PLAN ON REVERSES E '� <br /> jj FOR DEPARTMENT USE ONLY <br /> PHASE I �M , �� <br /> APPLICATION ACCEPTED BY . DATE 'A1 <br /> ADDITIONAL COMMENTS'.6 "`.R, a <br /> PHASE PI GROUT' INSPECTION *'k. ; PHASE I &INAL INSPECTION <br /> IN <br /> =INSPECTION BY DATE SPECTION BY A DATE �1g <br /> 8 -`2M <br />