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*"ems <br /> Y/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. L"-L�2 <br /> Telephone: (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7� <br /> This Permit Ex i.res .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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of. the San. Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name Phone 3 ' <br /> Address C.cJ City <br /> Contractor's Name License#&��Z Phone <br /> IS CERTIFICATE OF WORKMAN'S COMIPENSATIO'N I'NSURA,,CE ON FILE WITH SJLHD. YES 310 <br /> TYPE OF WORK (Check) : NEW 'WELL❑ DEEPEN (], RECONDITION ❑ DESTRUCTION( <br /> -WELL C,HLORINATION­CQ -;- WELL-ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR d PUMP REPLACEMENT E <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 SPECIFICATIONS <br /> -� Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled . Dia. of Well Casing <br /> Domestic/public 4 ,Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal__ <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: 5LState Work Done <br /> PUMP REPAIR: QState Work Done <br /> jDESTRUCTION 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 accordancE <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local , <br /> Health District. dome 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 sha11 <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 G UT INSPE ION PRI TO GROUTING AND AIFINAL INSPECTION. <br /> SIGNED TITLE: DATE: r I <br /> _)T <br /> DRAW PLOT E PL N ON REVERSDE <br /> FOR DEPARTMENT USE ONLY <br />'PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 77 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE f- ��� <br />