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SAN JOAQUIN LOCAL HEAL.1H UISIRI[ <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ~12--1.6-7. 3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 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 incompliance with San <br />�'oaqu i n County Ord i nanck Jo. 1862 and ,the Rules and. Regulations of the San Joaquin. Local Health <br /> EXACT STREE SS //SCK Ur L, CITY/TOW <br /> Owner's Name, Phone <br /> Address ' L-,L- Ci ty OL&M 6.r-s f <br /> Contractor' s Na e i c..' Licens o2 Q hone S''C^" 3 VC-t <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL L�DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION E] WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION !�' PUMP REPAIR❑ PUMP REPLACEMENT ❑ ' <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 Driven Gauge of Casing__—_ <br /> Irrigation Gravel Pack Depth of Grout Seal CI <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other I formation <br /> Geophysical Surfac eal Installed by: <br /> PUMP INSTALLATION: C o n t r a c r ,t4-1 vaan� J/V/? <br /> Type of Pump . u/A H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done s <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 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 CA /FOR A GNUT INSPECTIO P 0 ROUTING AND NAL INSPECTION. <br /> SIGNED x TITLE DAT : <br /> (DRAW PLOT PL N ON REV DE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE7 XZI <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE %g i' Xr <br /> r„ IA^r n--- .n -.-. - � I`70 1)M <br />