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�' �, `::rA• ... . - r.a-mat{ � r— a <br /> SAN JUAQUIN LOCAL. HEALTH UIS I RIC I- - <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No, - 3 .� <br /> Telephone: (209) 466-6781 <br /> -" Date Issued <br /> -APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT <br /> TKis Per6it. Ex fres 1 Year From Date Issued _Q <br /> Complete. In Triplicate <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 />,oanuin County Ordinance flu. 1862 a d the Rules and Regulations of the. San Joaquin -Local Health <br /> District. t '�3 <br /> EXACT STREET ADDRESSCITY/TOWN <br /> Owner`s Name Phone. <br /> Address ' ~ City , <br /> Contractor' s- Name- Licens Phone <br /> IS CERTIFI1CATE OF WORKMAN'S COMPENSATION TINSURANCE ON FILE WITH SJLHD? YES .Lr�NO <br />.TYPE OF WORK (Check} : ".NEW `WELLL DEEPEN Q RECONDITION ❑ DESTRUCTIONS] <br /> WE'LL- CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> m _ PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK ,,]-QO SEWER LLNES PIT PRIVY <br /> x* SEWAGE DISPOSAL FIELD 500 'r CESSPOOL/SEEPAGE PIT ETHER <br /> r ' �.• PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOME5 f IC WELL y <br /> INTENDED USE\ TYPE OF WELL m� ; ����ISTRUCTION SPECIFICATIONS , <br /> dustrial Cable Tool Dia. of Well Excavation <br />` Domestic/private Drilled Dia. of Well Casing 122. r <br /> Donestic/pubT�.ic.-- -�� _Drave - ---raugP-off Gas,ang _�� Q•_� �_: 4-:._ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection. L_-Rotary Type of Grout <br /> F Disposal Other Other Informationa 52 <br /> Geophysical - Surface Seal Instilled -by .- <br />`:PUMP f1'NSTALLATION: Contractor <br /> Type of,-,Pump 99 N.P. 73 <br />=PUMP REPLACEMENT:°. M State Work Dane <br /> PUMP .REPAIR: : QState Work Done <br /> LYA <br />�.�JESTRUCTION OF WELL: Well .Diameter.. '�_ Pproximate Depth <br /> Describe Material and Procedure <br />[I hereby certify that"'I"have prepared-.thi-s,'ap:pl_i:cation and that the- work will be done in_accor --- <br />[with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin 'LO <br /> lHealth District. Home owner or licensed agent' s signature certifies the following: - <br /> "I certify that in the performance of the work for which this pefit is issued, ,I- shall <br /> not employ any person in such manner as. to become subject to Workman' s Compensation <br /> laws of California. " t <br /> I WILL CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND A FINAL IOICTION. <br /> SIGNED 7 TITLE: -f DATE: �. <br /> JDRAW LOT PLN ON REVERSE SIDE . <br /> FOR DEPARTMENT USE ONLY <br />'PHASE I ' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION -7 PHASE III FINAL INSPECTION <br /> INSPECTION BY '.i\ DATE �' �T� � . `� INSPECTION BY DATE <br /> 097a `l�� <br /> 1 17 A <br />