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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. - <br /> Telephone: (209) 466-6781 <br /> Date Issued 7� � <br /> APPLICATION FOR WELL-.CONSTRUCTION OR PUMP PERMIT <br /> 6—/3 <br /> This, Permit Expires 1 Year From Date ,Issued <br /> Complete .In Triplicate , <br /> Application is hereby made to ,the San Joaquin Local Health District fora permit to -construct <br /> and/or installrthe work herein described., This applicattion is made in compliance with Sari . <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health € II <br /> District. t <br /> TR T ADDRESS [. J CITY/TOWN <br /> EXACTS EE f <br /> 0 <br /> Owner's Name <br /> Phone,33 .� i <br /> Address , 6,4_ I City <br /> Contractor' s Name <br /> } Li cense#J Phone 3 6, -.(''�'3 <br /> IS CERTIFICATE OF WORKMAN'S CO"•4PENSATIO'1 I"1SURA'10E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER F-3 - <br /> PUMP INSTALLATION 0 PUMP REPAIRER- PUMP REPLACEMENT C4 <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY_ <br /> SEWAGE' DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRI'VATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industri.aJ `_ <br /> ---:,Ca.ble-Tool—- Dia. of Well Excavation <br /> Domestic/private Drilled <br /> Di . of Well Casing <br /> g <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 i Surface Seal Installed b <br /> PUMP INSTALLATION:. _ _-_Co.n.tr.actor ;_ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ]State Work Done <br /> PUMP REPAIR: 'state Work Done <br /> _ f. <br /> r <br /> DESTRUCTION OF WELL: Well Diameter — Approximate Depth <br /> Describe Materia and Proce ure <br /> I hereby certify that 1 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 /> '1 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 FA A GROUT LNSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED E <br /> LE: DATE: - r <br /> W PLOT PLTN REVERSE DE <br /> FOR DEPARTMENT USE ONLY / <br /> PHASE I DATE 6 "j -` 20 <br /> APPLICATION ACCEPTED BY t <br /> ADDITIONAL COMMENTS: ► <br /> G PHASE II GROUT .-INSPECTION GROUT .—INSPECTIONPHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYE`', 1Y _ DATE 7 7 <br /> 1 /78 21A <br />