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�- SAN JOAQUIN LOCAL HEALTH Ui51RiLI <br /> FFICE USE: 1601 E. Hazelton"Aye. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 4466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> i y ,+ <br /> This Permit Expires I 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 the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS JCS CITY/TOWN � <br /> i <br /> Owner's Name r Phone .�� <br /> Address / e' gjn� City , <br /> Contractor' s Name Le A),�I", y- S.Q� Li cense#3`/aq y5! Phone 3(Q9 _---__- <br /> 'S CERTIFICATE OF WORKiiAN'S COMPENSATIO,! I11SURA"!CE ON FILE WITH SJLHD? YES .110 <br /> TYPE OF WORK (Check) : NEW WELLIK DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ � '� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER F-3 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 7,5' CESSPOOL/SEEPAGE PIT i)o6,e_ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> 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/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal SIQ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b �, <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 Approximate Depth <br /> Describe Material and Procedure <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 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 41- TITLE: DATE: 7 <br /> (DRAWPLOT PLAWON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,.�,� • DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT- INSPECTION , PHASE III FIN INSPECTION <br /> INSPECTION BY DATE 'Z, , . INSPECTION BY �L �� DATES Z�, C- <br /> J Ig26 Rev. 12-77 L/78 2M , <br />