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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 96205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Comp]ete I-n Tri pl mate <br /> Application is hereby made to th'p San Joaquin Local Heilth District for a permit to construct <br /> and/or install the work herein described: Thin application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. ;R \ <br /> EXACT STREET "ADDRESS o a Z CITY/TOWNS <br /> Owner's Name , Phone J�2/ <br /> Addres-sI* 6171�el , Ci ty mrfi <br /> Contractor's Name .� ,., {d Licenseg&r/ <br /> ,Zb Phone rf17- <br /> IS CERTIFICATE OF WORKr ANIS COMPENSATION TNSURAINCE ON FILE WITH SJLHD? YES :2: NO <br /> TYPE OF WORK (Check) : NEW WELLO DEEPEN ❑ RECONDITION Q DESTRUCTION <br /> WELL CHLORINATION Q WELL ABANDONMENT ED OTHER 0 <br /> PUMP INSTALLATION'P@- PUMP REPAIR O PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES -cam PIT PRIVY-0- <br /> SEWAGE DISPOSAL FIELD--e. CESSPOOL/SEEPAGE PIT --e.- OTHERS <br /> y PROPERTY LINE00rPRIVATE DOMESTIC WELL--- PUBLIC DOMESTIC WELL --� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation I ,. <br /> ,t- Domestic/private -Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ZLO zX <br /> Irrigation Gravel Pack Depth of Grout Seal ,-- <br /> Cathodic Protection _Rotary Type of Grout (- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal InstalledbY: I/a.. ,,, <br /> PUMP INSTALLATION: Contractor <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 /> Describe Material and Procedure <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 licensed 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 INSPEC N PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: Z �_ DATE: - s <br /> (DRAW PLOT L N ON REVERSE SIDE i <br /> 0 DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY z DATE Z <br /> ADDITIONAL COMMENTS: ! `y - <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY L-V ATE_ - 77 INSPECTION BY /-✓ DATE/If I <br /> z �� <br />_EH 1426 Rpv_ 12-�7 ` _ Wi ' S <br />