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J1 }� SAN IOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: -(209) 466-6781 <br /> pl'' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7- <br /> This Permit- Ex i 'es I ,Year From Date Issued . <br /> . Complete In Triplicate)' '., <br /> Application is hereby made to the San Joaquin Local .Health •District for permit to construct <br /> and/or install the work herein1described. This application is made in compliance with San <br /> U1aag1.Jn County Ordinance Nlo. `I862 and the Rules and Regulations of the San JoALo�al <br /> District• <br /> EXACT STREET ADDRESS £ e. <br /> CITY <br /> Name `-- ;L;- <br /> Owner' s Phon <br /> Address �? ,- City Contractor's Name License# /y 3 7 PhonIS CERTIFICATE OF WORKMAN'S MPFNSATIO'! Ii€SURAINCE nm FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL E] DEEPEN 0 RECONDITION Q DESTRUCTION C1 h' <br /> WELL CHLORINATION L WELL ABANDONMENT 0 OTHER F-3 ` <br /> PUMP INSTALLATION Q PUMP REPAIR OD PUMP REPLACEMENT 0 � <br /> DISTANCE TO NEAREST: SEPTICjTANK SEWER LINES PIT PRIVY ' <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE I TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private r -Drilled Dia. of Well Casing <br /> Domestic/public i Driven _ Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection A Rotary a Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION:. Contractor oa. H.P. 3 <br /> Type of Pump .r <br /> PUMP� REPLACEMENT: State Work Done` <br /> PUMP REPAIR: ®State Work Done g 1 2=Q - :Tit <br /> DESTRUCTION OF WELL: WeIl Diameter Approximate Depth <br /> Describe MateriaT and 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 , ignature certifies the following: <br /> "I certify that in the performance of the wor-k '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 INSPE ON RkOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ,(-T.ITLte. DATE: <br /> DRA PLOT L E: r <br /> N•REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 7/D -2k?"' -- <br /> , ArPLICATION ACCEPTED BY <br /> `ADDITIONAL COMMENTS: <br /> 4 PHASE II ROUT INSPECTION PHASE III FINAL INSPECTION <br /> (INSPECTION BY DATE INSPECTION BY _ DATE /O <br /> ,n -7-7 - 8 2M <br />