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SAN JOAQUIN LOCAL HEALTH 01STRICT <br /> FFICE USE: 1601 E. Hazelton Ave, , Stockton, CA 95205 Permit No.- <br /> Telephone: (209) . 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued s'//'7 j <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 /> ,oaquin County Ordinance No. 1862 and the' Rules and Regulations of th.e .San Joaquin Local Health <br /> DiStr;ct. <br /> EXACT STREET ADDRESS � '� CITY/TOWN, <br /> Owner's NamePhone ZZ:�pJ � . <br /> Address Ar, City <br /> Contractor' s Name�7— /9 License4 '- phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATTO'I INSURANCE ON FILE WITH SJLHD? YES NO j <br /> TYPE OF WORK (Check) : NEW WELL PJ--- DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑i <br /> PUMP INSTALLATION [a PUMP REPAIR❑ PUMP REPLACEMENT M <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 SPECIFI AT;ONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 7-Domestic/private Drilled Dia. of Well Casing � <br /> Domestic/public Driven - Gauge of Casing l <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection --LZotary Type of Grout Z�"�'r�/ 1 �- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b L <br /> PUMP INSTALLATION: Contractor <br /> �-,-/-�q <br /> Type of Pump H.P. J <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well ' Diameter Approximate Depth <br /> Describe Material an2 Procedure <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 FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEQ TITLE : <br /> ��� � DATE: <br /> RAW PLOT PL N ON REVERSE SIDE A <br /> FOR DEPARTMENT USE -ONLY' ' <br /> PHASE I <br /> APPLICATION ACCEPTED �BY DATEC� <br /> ADDITIONAL COMMENTS : : �; �,. <br /> PH SE. II GROUT: NSPECTION ; PHASE; I FIP INSP TI <br /> INSPECTION 8Y DATE_ f f.7 INSPECTiOFV BY DATE -� <br />