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,T e &. <br /> A& SAN JOAQUIN LOCAL HtALI-H D15IKIUI <br /> ! FOR OF ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. � _/sem o <br /> Telephone.: (209) 466-6751 <br /> APPLICATION .FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application' is hereby made to the San Joaquin _Local Health District for a permit to construct <br /> and/or instal' the work herein described.. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and tbLe Rules and Regulations of the San Joaquin Local- Healt'h <br /> District. G <br /> EXACT STREET ADDRESS Q- 7.. / CITY/TOWN <br /> Owner's Name Phone <br /> Address y/ .City sus <br /> Contractor's Name Li cense# 1y37i1' 11T one c69 y -16 Z-X <br /> IS CERTIFICATE OF WORKMAN'S CAMPENSATION INSURANCE ON FILE WITH SJLHD? YES '10 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIRRI PUMP REPLACEMENT Q ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY V <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL \ <br /> INTENDED USE 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 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 -• '4� ,J/f, H.P. <br /> PUMP REPLACEMENT: 7IState Work Done <br /> PUMP REPAIR: [State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material 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 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 INSPE TION P34R TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE ITLE: TE: <br /> ON REVERSE S <br /> P I R DEPARTMENT USE NL 1''Io,<�z J(A.^^U+'Or, k <br /> A. !CATION ACCEPTED BY a.�, u- 1_ZI_�2 - S¢"^� - DA � <br /> ADDITIONAL COMMENTS: - ; ern / 3 1 <br /> PHASE II GROUT INSPECTION PHASE III FIN INSPECTION <br /> INSPECTION BY DATE INSPE ION BY DATE <br /> Cu 1AOC n- ,7 77 1 /-7Q <br />