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_ P Y_ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'F USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> Date Issued3- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires 1 Year From Dat Inst - 5e W ^ ,.� <br /> Complete In Triplicate 12- 7- � � • <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. This application is made in compliance with San <br /> ,cams» County Ordinance No. 1862 and the Rules and Regulations of the San Joaaquin Loc 1 Health <br /> EXACT STREET ADDRESS �j /��f CITY/TOWN <br /> Owner' s Name Phon <br /> Address v iva7� Ci ty `7ywrc.�x/ -_ <br /> Contractor's Namese <br /> j-r License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES 140 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION (D DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Ley <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 6� <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 f W <br /> Type of Pump I H.P. - <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter �{ A proximate Depth O <br /> Describe Mttprial and Procedure <br /> Arid- <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 l-ic-ensed-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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DRAW PLOT PL N ON REVERSE SIDE <br /> PHASE i FOR DEPARTMENT USE ONLY -7-12-,-7,f <br /> /0 APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />,FH 1426Rev._-12-7 Z_ a..��- -G9 LGt -�-Gzr - - - /7.8 _2M_ <br />