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.. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FrICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ,7�- fr-2- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �- <br /> This Permit Ex ires 1 Year From- Date Issued . <br /> i. . Complete In Triplicate <br /> AppTication is. hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereinldescri•bed This application is-made in compliance with San . <br /> Joaquin County Ordinance Nd. 1862 and the -Rules and Regulations of the San Joaquin Local Health <br /> District. Z y�j <br /> EXACT .STREET ,ADDRESS - - / N CITY/TOWN <br /> Owner's Name Y-N-� W',e"hJPhone , <br /> Address City Q*y-r <br /> -- - - _ <br /> Contractor' s Name "' �� icense G Phone 7- <br /> t <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES N0 <br /> TYPE OF WORK (Check) : NEW WELLM} DEEPEN CI RECONDITION DESTRUCTION(-_) <br /> WELL <br /> ESTRUCTIONC- <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER r,.3 <br /> PUMP INSTALLATION ❑ PUMP ;REPAIR 0 PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES AV PIT PRIVY�1� <br /> SEWAGE DISPOSAL FIELDV CESSPOOL/SEEPAGEIP TN& OTHER <br /> PROPERTY LINE&;PRIVATE DOMESTIC WELL J�d _.. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> =Drilled Drilled Dia. of Well Casing <br /> Domestic/public t Driven Gauge of Casing ( -5 1 _ G_:P <br /> Irrigation —Gravel Pack Depth of Grout -Seal. -Cathodic Protection 'Rotary Type of Grout <br /> Disposal . Other Other Information <br /> Geophysical;, Surface Seal Install edb p A)—T' , <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-. - ;u �lApproximate Depth <br /> Describe Material and Procedure i <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 aR tOROUT INSPE IDN PRIOR TOfG.ROUTING AND F.IN L INSPECTION. <br /> SIGNED TITLE• DATE: r� <br /> DRAW PLOT PL N ON RE SE SIDE <br /> FO PRTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYme. DATE <br /> ADDITIONAL COMMENTS: LIZ { <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSRECTION <br /> INSPECTION BY DATE, INSPECTION BY TE <br />�u rtahr " oo„ ��_��.. . - 1 /7R 2M <br />