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SAN J0AQUIN..L0CAL, HtAL1H U.15IRILI <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton,, CA 95205 Permit <br /> Telephone: (209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires I Year From Date Issued <br /> Complete In Triplicate <br /> 't � <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 /> Joaquin County Ordinance No. 1862 and the Rules,. and Regulations of the San. Joaquin Local Health <br /> Distrwct. (' 7-5, � A <br /> EXACT STREET AD' ESS , —�`' CITY/T0WV % f <br /> Owner's Name Phone":7-S <br /> Address Ci ty��Q �� ry <br /> Contractor's Name 4-1-1-9 License#) -)-�37-:�Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO+"1 I"ISURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION [:3 DESTRUCTION <br /> WELL CHLORINATION p WELL ABANDONMENT ❑ OTHER 0 � <br /> PUMP INSTALLATION ❑ PUMP REPAIRG�L, PUMP REPLACEMENT C] <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 i <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 <br /> Cathodic Protection Rotary Type of Grout z <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 ' 4Q a <br /> PUMP REPAIR: C State Work Don <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 WDrkman's Compensation <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ap - TITLE: DATE: 7� <br /> DRAW PLOT PLAN ON REVERS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYZZdje� DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �=�!A nyr <br />