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Ga �u12)t 6L4f SAN JOAQUIN LOCAL-HEALTH DISTRICT � <br /> REICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. a <br /> Telephone: (209) 466-6781 r <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ices .1 Year. From Date Issued. <br /> Complete In Triplicate <br /> Application is hereby made toq the San Joaquin Local Health District for a permit to construct <br /> and/car install the work' hereirildescribed. This application is made in compliance with San <br />�oan ��n County Ordinance ado. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> k - <br /> EXACT STREET ADDRESSf3 d ' r CITY/TOWN UG <br /> Owner's Name <br /> .. I� . Phone <br /> Address - City <br /> Contractor' s Name �.�v Li cense#11,93 7=-.1�Phone_^ 7-- 6 7-6_- ' <br />--I.S CERTIFICATE OF WORKMAN'S &Mi ENSATIO'N INSURhINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION C ❑ DESTRUCTION <br /> WELL <br /> N M WELL CHLORINATION C] WELL <br /> PUMP INSTALLATION ❑ PUMP REPAIR[?) PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY PIT OTHER <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEE <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We11 Excavation r <br /> -Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Depth of Grout Seal <br /> Irrigation Gravel Pack <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical . . . -__-Surface Seal- Installed b <br />' PUMP INSTALLATION: Contractor �' 4 k"''-• <br /> H.P. <br /> Type of Pump - <br />[ PUMP REPLACEMENT: ]State Work Done : 4 <br /> PUMP REPAIR: OStalte Work Done ~"" <br /> DESTRUCTION OF WELL: Well DAroximate iameter - pp Depth <br /> Describe Material and Procedure <br /> I hereby certify that I havei:prepared this application and that the work will be done in accordanc( <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 /> illaws of California." t-1 <br /> WILL CALL FOR .A GROUT INSPECTJON FRI,Q TO GROUTING ,AND A FINAL INSPECTION. <br /> ITLE: 4� DATE: Y <br /> SIGNED DR W PLOT PLRN ON REVERSE SIDE <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I DATE � <br /> (APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUTiINSPECTION PHASE III FINAL INSPECTION <br /> [INSPECTION BY DATE INSPECTION BY k5p DATE ,6 -J> `, <br />