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/1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: E. Hazelton Ave. , Stockton, CA 95205 Permit No. #3-k2 <br /> Telephone: (209) 466-6781 <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 by made to �the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein[described. . .This -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. <br /> EXACT STREET ADDRESS jl� �-- `, . ri' . CITY/TOWN r r <br /> Owner's Name _zy; D, Phone <br /> Address --7 Ci ty r % � <br /> Contractor' s Name - . � r� k-- e, - Li cense#J C4'?&()- _ Phone 5�3 -- <br /> TS CERTIFICATE OF WOP,KIIAN'S CO?ZPENSATION IINSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN 0 RECONDITION DESTRUCTION d N ; <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATIONyg, PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK too SEWER LINES PIT PRIVY r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL W <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 i Driven Gauge of Casingt,� <br /> Irrigation 1 Gravel Pack Depth of Grout Sea <br /> Cathodic Protection I Rotary Type of Grout C <br /> Disposal i Other Other Information k <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor R <br /> Type of, Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done } <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter " "'" ``'"`"'""` Approximate---Depth <br /> Describe Materia7 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 /> "F 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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED , TITLE: DATE: <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEP RTMEN . USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATF/� Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY,% DATE%/Z�� <br />