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' 1 <br /> SAfi JOAQUIN LOCAL HLALIH UiSIRILI <br /> FOR FFICE USE: 1601 Hazelton Ave. , Stockton, CA .05 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issuedz5- -? <br /> This Permit Ex fres 1 -'Year From Date Issued <br /> (Complete In Triplicate <br /> Aoplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> dnd/or install the work herein described. This application- is made in compliance with San <br />,oaquin County Ordinance No. 1862 and the Rules and Regulations 'of the San Joaquin Local Health <br /> Ci strict. 1 4T-37 <br /> EXACT STREET ADDRESS1 �ry CITY/TOWN�C <br /> Owner's Name -'; Phoneja¢S=69 / <br /> Address X57 Cc7 / / % City .���./ <br /> Contractor's Nam �� ('a, Licensel3o/�S PhoneF ,a�["5 ;X1 <br /> IS CERTIFICATE O IJORKIIAN'S CO!SPENSATION INSURA"ICE ON FILE WITH SJLHD? _ YES NO <br /> TYPE OF WORK (Check) : NEW WELL Q• DEEPEN Q RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION O WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST:, ' SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIS OTHER <br /> _ PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF. WELL :" <br /> - CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia: of We 1 Excavation <br />�DomeStic/private Drilled ,'. Dia. of Well Casing <br /> Domestic/public +r-Driven, Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection TRotary Type of Grout � <br /> Disposal Other,-i Other Information _ <br /> . Geophysical ' — ""— Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor } ` <br /> Type of Pump:; , /� H.15. <br /> PUMP REPLACEMENT: rJState Work.Done` <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL Well Diameter Approximate Depth <br /> Describe: 'Material and Procedure 7 <br /> s <br /> I hereby certify that I have. prepared this application and that'- the work will be done in accordant <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 A GROUT INSPECTI N PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:—Z�7 <br /> (DRAW L T P OW REVERS ' SIDE <br /> FOR DEPARTMENT USE 'ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE `�� ` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY.,0 ,'' DATS�=' ;i <br />