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- SAN JOAQj1IN:1,QCAL HEALTH DISTRICT <br /> ter . <br /> FFICE USE: 1601 E. Hazelton Ave.; Stockton, CA 95205 Pen-nit- ., ?-jn I� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT, Date Issuedke <br /> ' 7� <br /> -- <br /> This Pe,rmi t, Ex ~i res: 1 Year From Date' Issued <br /> . Complete In Triplicate <br /> F Application is hereby made to the San Joaquin' Local Health District fora permit to construct, <br /> and/or install the work herein described.° . This application is made, in compliance with San <br /> Joaquin County Ordinance No. 11862 and the Rus d 'Regulations of the San Joaquin 'Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOW <br /> Owner' s Name Phone <br /> Address z City - <br /> Contractor's Name -":L�cense# Phone �Z�43 <br /> IS CERTIFICATE Nal <br /> ORK4H\ irS hMPEN TION! INSURA"!LCE ON FILE WITH SJLHD? YES NO <br /> r -= w <br /> TYPE OF WORK (Check) : NEW WELL C)DEEPEN Q RECONDITION �DESTR'UCTION❑ lv <br /> 4 WELL 'CHLORINATION p WELL ABANDONMENT 0 OTHER 0 <br /> -PUMPT�fSTAf�LATION�Ca `PUNfP REPAIR❑ PUMP-}REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC, TANK SEWER LINES PIT PRIVY tY1 <br /> r ; SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL _ <br /> -.-,,....w.�M---- ""'CONSTRUCTION SPECIFIC4TtONS <br /> i Industrial Cable Tool Dia. of Well Excavation <br /> ,Domestic/private Drilled Dia:. of Well Casing =C <br /> Domestic/public Driven - ~`Gauge ;of -Cas i ng - <br /> IrrigationGravel Pack Depth of Grout -Seal <br /> Cathodic Protection/ =Rotary Type of Grout ' . -� - <br /> iDisposal Other Other Information _ .F <br /> Geophysical Surface Seal Instal ed by': <br /> PUMP INSTALLATION: Contractor „_. "� Vi <br /> Type of Pump H.P. <br />' PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: � ❑State Work Done . <br /> DESTRUCTION OF, WELL: Well Diameter Approximate Depth <br /> I Describe Material and Procedure <br /> I hereby certify that%I have prepared this application and that.--t.he work: wil-1 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 i"ssued,,1I shall <br /> not employ any person\fin such manner as to become sub ' t to- s Compensation <br /> laws of Ca 'fornia. " \ � <br /> I WILL CALL A GROUT INSPECT PRIOR TO GRDIlTING,•AND Aj1NALSIGNEDTITLE: ATE: f <br /> DRAW PL T PL N ON' REVSIDE--` <br /> FOR D P <br /> E ARTMENT TZONCY <br />' PHASE I <br /> APPLICATION ACCEPTED BY DATE (� 4 <br />' ADDITIONAL COMMENTS : - _ < <br /> PHASE II G OUT INSPECTION' -PHASE III- FINAL INS CTION <br /> INSPEGTiON BY DATE C-,INSPECTION -BY. . DATE ]]] <br /> 1 r2 <br /> I'�EH 1426 Rev_ 12-.77 Ixg <br />