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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOR OFFICE USE: 1601 E. Hazelton Ave. , <br /> Stockton, CA 95205 Permit No. S <br /> Telephone: (209) 466 -6781 pate Issued - 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit' tx fres I Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local - Health -District for apermit to construct <br /> This - <br /> and/or install the work herein described. This application is made in compliance with San 4 <br /> .and Regulations of the San Joaquin Local Health 1 <br /> Joaquin County Ordinance No. 1862' and the Rules <br /> District. �'� �. ZL)fI i 7E�S <br /> EXACT STREET ADDRESS n 7 Phan <br /> 3 <br /> CITY/TOWN& �m <br /> p;�,��s�TOn `�� <br />�- <br /> Name �...� <br /> Address. � . C i ty�_ � <br /> ��b 1lr a3o <br /> 1 v { Li cense# Phones <br />.Contractor's Nam <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION I'dSURAINCE ON FILE WITH SJLND? YES NO <br /> TYPE OF WORK (Check) : NEW WELLt4 DEEPEN ❑ RECONDITION ® DESTRUCTION C� <br /> WELL- CHLORINATION WELL ABANDONMENT ❑ OTHER❑ � -_.._.. _ .__. ...- <br /> PUMP INSTALLATION $l PUMP REPAIR❑ -PUMP—REPLACEMENT C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK YaaL SEWER LINES PIT PRIVY <br /> LINEPRIVATESTICPWOLLSEI D. PUBLIC DOMEEPAPE PIT STIC SEWAGE DIIWELL <br /> PROPERTY _ <br /> INTENDED USE TYPE 'OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Ex'cav'ation <br /> Dia. of Well„Cd'' ing ” <br />` ^Domestic/private Drilled Gauge of Casing-- d <br /> Domestic/public Driven , <br /> Irrigation Gravel Pack Depth of Grout Sea , <br /> Type of Grou �N <br /> E Cathodic Protection Rotary ' Other <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> �e <br /> PUMP INSTALLATION: Contractor H.P. <br /> 4 <br /> Type of Pua+p . � . ;kI7 . <br /> PUMP REPLACEMENT: State WorO'Done .: <br /> PUMP REPAIR: ❑State Work ;Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ( Describe Materia an Proce ure ' <br /> I hereby certify that I have prepared. this application and that the work will be done in accordan( <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 perschance of manner as toork for which become subjecthis to Workman' s Compensatioermit is issued, I n not employ any person in such <br /> laws of California." tw' <br /> 1 . <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE: DATE: //- <br /> SIGNED DRAW PLOT PL N ON -REV RSE SID <br /> F DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ; ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> f PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION BY d _ DATES 9f <br /> r 8 2M <br />