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I SAN JOAQUIN LOCAL HEALTH DISTRICTFA Per€ni Na, 7� 3 <br /> FF=ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 <br /> Telephone: (209) 466-6781: ' <br /> ;� � Date Issued -!� -7 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT , <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> herebymade to .the San Joaquin Local Health District for a permit to construct <br /> Application �s <br /> and/or install the work hereinidescribed. 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. CITY/TOWN <br /> TY) <br /> EXACT STREET AODRES A -5 -� . <br /> Phone <br /> Owner's Name ` <br /> Address °1 City <br /> Contractor' s Name ' License#P o Phone / <br /> ' ""PEPJSATIOP! I�SSURA'�CE ON FILE WITHSJLHD? YES �� NO <br /> IS CERTIFICATE OF WORKMAN S Cn <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> 4J <br /> PUMP INSTALLATION ❑ PUMP REPAIR,l PUMP REPLACEMENT C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY s <br /> SEWAGLIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �b1 <br /> µ, L 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/publ i c Dri ven,; Gauge,.of,:, Casing <br /> {, l� Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> - Geophysical ' Surface Seal Installed by: <br /> i PUMP _INSTALLATION: Contracto Ao _ y H.P. <br /> Type of Pump <br /> f ' <br /> POMP `REPLACEMENT: []State Work Done <br /> - - _. <br /> PUMP REPAIR: State Work D 'one <br /> _'-t— -_ _ _ Approximate Depth' <br /> DESTRUCTION OF WELL: Well Diameter <br /># { Describe Material and Proce ure <br /> ' Thereby certify that I havelprepared this application and that the work will be done in accordanc+ <br /> withSan 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 /> i not employ any person iniisuch manner as to become subject to Workman's Compensation <br /> f laws of California." f <br /> I `WILL CALL FOR A GF UT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: ���`J� <br /> € -DR W PLT L N ON REVERS SIDE <br /> _F OR DEP RTMENT USE ONLY <br /> PHASE I DATE 5 <br /> ` APPLICATION ACCEPTED BY / <br /> ADDITIONAL COMMENTS: PHASE IIT I L INSPECTION <br /> PHASE II GROUT,:INSPECTION _/ <br /> INSPECTION BY DATE ^� INSPECTION BY DATE <br /> � - _ 32M. <br />