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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE�USE: 1601 E. Hazelton Ave. , Stockton, CA, 95205 Permit No. <br /> Tele hone: <br /> p (209) 466-6781 <br /> F­ _f\ 2— <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex i:res. 1 Year From Date Issued <br /> Complete In Triplicate <br /> 2_5 22- 0 2-0 ­1 <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. Thi`s -application ' is !made in compliance with 'San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. R, w . j` - icc e, )A,,� <br /> EXACT STREET ADDRESSCITY/TOWN <br /> Owner's Name Phone <br /> Address-, <br /> C i ty_ � <br /> Contractor's Name License#.3 Phon _ 64 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA"1C�1`ILE WITH SJLHD. YES NQ <br /> TYPE OF W� l <br /> ORK .(Checfc)-: � NEI��,W_ELL �, � DEEP__E11-L7:;�.=, RE.GOI�DI-_T_IDN.:.� DES7RU.CT.�:Oi•J�:�=��;•--..�-_,-_�_-�. . - ��; <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 <br /> PIMP INSTALLATION PUMP REPAIR(] PUMP REPLACEMENT [I 5 <br /> DISTANCE TO NEAREST: SEPTIC TANK �I SEWIN�S___ ��OO PIT PRIVY <br /> SEWAGE DISPOSAL FIELD .ESSPOO W SEEPAGE PIT OTHER 1 <br /> PROPERTY LINE -. PRIVATE D MESTIC+WELL .._&L PUBLIC DOMESTIC WELL �4a <br /> INITENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS F <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing "r <br /> Domestic/public Driven Gauge of Casing 6 <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 a n <br /> Type of Pump <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: C]State Work Done •' _ .. ; . <br /> DESTRUCTION OF WELL: Well Diameter <br /> . I Describe Materia an Procedure Approximate Depth s <br /> I hereby certif "that I have <br /> Y e 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 DiStH ct. '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 em6loy ,a.ny person; in .such manner- as to become subject to Workman 's Compensation <br /> laws of CaT7fornia. " <br /> I WILL CAL ;,FR A GROUT NSPECTION PR OR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED „ `'' r TITLE: DATE: h <br /> RAW PLOT PLAY ON REVS SE SID <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED. BY �— a, DATE <br /> ADDITIONAL COMMENTS : <br /> PASPASE II IROUT INSPECTION PHAS III ,FINAL INSPECTION ' <br /> INSPECTION BY DATE_°Z `ZZ INSPECTIONBY DATE <br />�H 1426 - ...,Rev 12-77 1 170 1)ILA <br />