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CO l <br /> �'^ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ./dad <br /> Telephone (209) 466-6781 <br /> A �-�8� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date IssuedjA_ <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 for a permit to construct <br /> and/or install the' work herein described. This 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. <br /> EXACT STREET ADDRESS x­1 In l��h > CITY/TOWN <br /> Owne'r's Name Phone <br /> Address. 2J77 lyre �-e -City <br /> Contractors Nam License# —hone <br /> IS CERTIFICATE OF WORKMAN'S CO"'IPE ITI OY INSURANCE ON FILE WITH SJLHD? YES 1110 <br /> TYPE OF WORK (Check) : NEW WELL CI DEEPEN RECONDITION ® DESTRUCTION E2 � <br /> WELL CHLORINATION Q WELL ABANDONMENT ® OTHER <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT [:J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER " <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <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 b <br /> PUMP INSTALLATION: Contractor > <br /> -- Type of Pump _C- H.P. <br /> PUMP' REPLACEMENT: [] State Work Done <br /> PUMP Rzzw: Qi�State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <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 Lacal , <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 shal•1 ;�_- <br /> not employ any person in such manner as to become subject to Workman 's Compensation-_ `�-_ � <br /> laws of California. " <br /> I WILL CAL FOR A GROUT INSPEC P I.QR 0 GROUTING AND A FINAL INSPECTION. <br /> SIGN ITLE: DATE: <br /> LOT PL N REVERSE SIDE <br /> FOR D PAR MENT U E ONLY <br /> PHASE i <br /> APPLICATION ACCEPTED BY //(c DATE 7c� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPE ION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> .. __ ... 1 170 Om <br />