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SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FQR FF E USE: 21601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL-CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Is'sued' <br /> Complete In Triplicate) ' <br /> 1pplication is hereby made to the San Joaquin. Local Health District .for a permit to construct <br /> !nd/or install the work herein described. This application is made .in compliance with San <br /> 'oan-,in County Ordinance No. 1862 and the Rules and Regul.ations of the San Joaquin . Local. Health <br /> )istrict. <br /> :XACT STREET ADDRESS Q -CITY/TOWN <br /> )wner's Name �r. rr � r/,�,�,� Phone <br /> �d d re s s 4 /✓ /3 City <br /> ;ontractor's Name License# I �yd'Phone 4,Y ZG 2 <br /> CS CERTIFICATE OF WORKMAN'S CO14 ENSATIO'N INSURANCE ON FILE WITH SJLHD? YES NO <br /> 'YPE OF WORK (Check) : NEW WELL M DEEPEN CQ ` RECONDITION DESTRUCTIONE) <br /> WELL CHLORINATION C1 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION p PUMP REPAIR O PUMP REPLACEMENT 0 t <br /> )ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY - -L <br /> SEWAGE. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT . OTHER s <br /> PROPERTY LINE -. PRIVA E) D MESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation dee <br /> Domestic/private Drilled 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 <br /> 'UMP INSTALLATION:." Contractor ct , J <br /> Type of Pump .9 H.P. <br /> 'UMP REPLACEMENT: [] State Work Done <br /> 'UMP — []State Work Done <br /> )ESTRUCTION OF WELL: Well ,Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <br /> hereby certify that I have prepared this application"and that'the work will be done in accordar <br /> rith San, Joaquin County Ordinances , State" Laws, and Rules and Regulations .of the San Joaquin Locz <br /> lealth 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 GROUT INSPECT P I4R—T GROUTING AND A FINAL INSPECTION. <br /> IGNE.D LE : DATE: /;7J <br /> PLOT PLANnN REVERSESIDE) <br /> FOR DEPARTMENT E ONLY <br /> 'NASE. I <br /> APPLICATION ACCEPTED BY. _�z DATE /_f /hf <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE' III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE <br />