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SAN JOAQUIN,L:OCAL. HEALTH DISTRICT <br /> FFICE USE,: 1601 E. Hazelton Ave: ; Stockton, CA 95205 Permit No, <br /> Telephone: - (209) 466-6781' . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ 3-2 <br /> This, Permit: Ex fires + I .Year, .From .Date Issued <br /> rComplete ,In Triplicate ' e " c . <br /> Application is hereby made to the San Joaquin Local Heal'th, Dstrict for a permit to construct <br /> and/or` install the>work herein described.- Thrs .applicati-on- is made in compliance w'ith .San . <br /> ,caq,"in County' Ordjnance­ ,o. 1862 an the Rules and Regulations of the San Joaquin Local: Health <br /> Clistr�ct. <br /> EXACT STREET_ ADDRESS; . <br /> . CITY/TOWNL,.fi-7 <br /> Owner' s Name <br /> Phone /� <br /> Address -� � _ _ City. <br /> Contractor's Name J_7-79 J Licensew"73 Phan <br /> IS CFRTIFICATE OF WORKt1AN'S COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : "NEW WELL Q DEEPEN ❑ RECONDITION ®_-- DESTRUCTION O <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION CM— PUMP REPAIR Q PUMP REPLACEMENT C3 <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 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : <br />'UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />'UMP REPLACEMENT: Q State Work Done <br />'UMP REPAIR• QS`tate Work Don <br /> rESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br /> lith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> ealth 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 /> WILL CALL FOR A GROUT INSPECTION PRIOR TO' GROUTING .AND A FINAL INSPECTION. x <br /> IGNED TITLE: DATE: <br /> DRAW PLOT PL N ON REVERSE IDE - <br />-LASE I FOR DEPARTMENT US ONLY k <br />'PLICATION ACCEPTED BYDATE <br />]DITIONAL- COMMENTS: <br /> PHASE II GROUT INSPECTION V PHASE III FINAL INSPECTI N <br /> ISPECTiON BY DATE INSPECTION BYDATE <br /> 44� <br />