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�- --= SAS! JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 <br /> I 7f <br /> Telephone: .(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3-15- <br /> _ - • <br /> This Permit Ex ires• 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 11�s ', <br /> and/or install the work herein described. This application' is made in compliance with San <br />�oaqu�n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. CITY/TOdO <br /> EXACT STREET ADDRESS _Z1 WN <br /> Owner's Name {Phone 3: eq— _ <br /> Address City <br /> Contractor' s Name °yLicenseL Phone / 2 <br /> IS CERTIFICATE OF WORKMAN'S tOMPENSATIO'N INSURANCE ON FILE WITH *SJLH-D? YES NO <br />-TYPE- OF WORK (Check) 'NEW WELLIJ DEEPEN _ RECONDITION ❑ DESTRUCTION[) <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ® PUMP REPAIR❑ PUMP REPLACEMENT ❑ A <br /> DISTANCE TO NEAREST: SEPTIC TAN K_1_6--z7-k SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE, PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL 'PUBL-IC 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' CaSi-ng f <br /> Domestic/public Driven - Gauge of Casing'_ - <br /> Irrigation Gravel Pack Depth of Grout Seal d <br /> Cathodic Protection _x Rotary Type of Grout " <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br />' PUMP INSTALLATION: Contractor ? <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑State Work Done 4 <br />,DESTRUCTION-OF.-WELL: Wel-1 Diameter Approximate`,Depth^ <br /> Describe Material and Procedure , <br /> r <br /> I hereby certify that I have prepared this application and -that the work will be done in accordan( <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: F <br />€ "I certify that in the performance of the work for which this permit is issued, I shall T <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 ANDA FINAL INSPECTION. <br /> SIGNED TITLE:, DATE: S O <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />[PHASE I <br />(.APPLICATION ACCEPTED BY DATES"1 '3`�L9 <br /> JADDITIONAL COMMENTS: <br /> PHASE II 5ROUT INSPECTION f PHASE III FINAL INSPECTION l <br /> INSPECTION BY I DATE L!• INSPECTION BY //9 DATE , �- 2� <br />