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_FOR OFFICE USE: 1601 E. Hazeltan'Ave. , Stockton, UA 'J0cuD <br /> Telephoner (20g) 466-6781 Date Issued —7f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex fres 1 Year From Date Issued <br /> Complete in Triplicate <br /> made to the San Joaquin Local Health District for a permit to construct <br /> is hereby is made in compliance with San <br /> Application17cat�on <br /> and/or install the work herein described. This app <br /> in Count Ordinance No. 1862 and the Rules and Regulations of the San ,Joaquin Local Health <br /> Joaquin Y � <br /> y CITY/TOWN �'_�C <br /> District. <br /> EXACT STREET ADDRESS �.�3Q `�`'v' ' <br />� Phone <br /> Owner's Name City" <br /> Address - . ` License#�f' Phone <br /> z.. <br /> lContractor's Name N0 <br /> � <br /> T "1AN'S COIiPENSATIO11 INSURA"10E All <br /> IS CERFILE 1r1ITIi SJLHD? YES a� <br /> CERTIFICATE OF 14ORK <br /> 10 DEEPEN ❑ RECONDITION C] DESTRUCTIONED <br /> TYPEAOF WORK (Check) : WELLWCHLORRINATION [3 WELL ABANDONMENT ❑ OTHER�] <br /> PUMP INSTALLATION tR-*' PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD pOMESTICCE—SsPWOELLSEEPAGEPUB OTHER <br /> PROPERTY LINE PRIVATE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Cable Tool Dia. of Well Excavation <br /> Industrial Dia, of Well Casing tr <br /> Domestic/private Drilled <br /> Driven Gauge of Casing '� <br /> Domestic/public Gravel Pack Depth of Grout Seal <br /> Irrigation Rotary Type of Grout , C__ <br /> Cathodic Protection 1Other Other Information <br /> Disposal - Surface Seal Installed b <br /> Geophysical <br /> PUMP INSTALLATION: Contractor H,p, <br /> Type].of Pump <br /> PUMP- REPLACEMENT: p State Work Done,i <br /> PUMP REPAIR: ❑State Work Done <br /> Approximate Depth <br /> FDESTRUCTION OF WELL: Wellkameter. <br /> 6 Describe Material and Proce ure <br /> be <br /> in <br /> I hereby certify that I have prepared this applicationlesdandaRegulationst the work woflthe San eJoaquin oLocl <br /> with San Joaquin County Ordinances, State Laws , and Ru <br /> kHealth District. Home owner or license tnenworksforawhichure cthisfpermiteisoissuedg� I shall <br /> "I certify that in the performance <br /> not employ any person in such manner as to become subject to Workman' s Compensation <br /> laws of California." i <br /> I WILL CALL FOR A GROUT IN PRIOR TO GROUTING AND A FINAL INSPECTION. DATE. <br /> TITLE: <br /> SIGNED <br /> DRTW PLOT P NON REVS SE D£ <br /> I <br /> FOR DEP RTMEN7 USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III # I AL INSPECTION <br /> PHASE II GROUT I N S P ION INSPECTION BY DATE <br /> 1INSPECTION BY DATE f� 7 orf/J <br /> .. .E <br />