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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ,y-)6�� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued F. <br /> Complete In Triplicate <br /> IE 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 in compliance with San <br /> Joaquin County .Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. td, s /lock 4c� o; <br /> EXACT STREET ADDRESS �, m {� 0f CITY TOWN <br /> / -_ <br /> Owner's NamePhone <br /> Address- R0. -Box to 13 City L.f VQOp . . . <br /> Contractor's Name <br /> WJkL License# 0Z. Phone y(�Z- <br /> I' <br /> IS CERTIFICATE OF WORKISAN'S COMPENSATIO°d 111SURAINCE ON FILE WITH SJLHD? YES Ido <br /> n. <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION DESTRUCTION 0 v�� <br /> t WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> ► PUMP INSTALLATION 0 PUMP REPAIR 0 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 :USES TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> dustrial Cable Tool ' Dia. of Well Excavation Z' <br /> Domestic/private Drilled Dia. of Well Casing 19" <br /> Domestic/public Driven Gauge of Casing # 1` 4 <br /> Irrigation I vel Pack Depth of Grout Seal <br /> Cathodic :Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical 5� Surface Seal Installed by: <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: p State Work Done <br /> PUMP REPAIR: O State Work Done <br /> DESTRUCTION OF WELL: We:11 Diameter Approximate Depth <br /> Desari-be Material and Proce ure , t+,e <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin' Codnty 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 fn 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 to4Workman's Compensation <br /> laws of California." > IN /' .,t 1/ / I f <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING M A FINAL INSPECTION. <br /> SIGNED : ' ' . Q" <br /> TITTLE: DATE: U D <br /> (DRAW-PLOT PL N ON REVERSE SIDE d <br /> t FOR DEP RTME USE ONLY <br /> PHASE I - <br /> PP-LICATION ACCEPTED; BY4 g <br /> °- DATE 0 /4 { <br /> ADDITIONAL COMMENTS: –• - _. _ . a <br /> PHASE II GROUT° INSPECTION PHASE III INAL IN PECTIO <br /> INSPECTION BY DATE INSPECTION BY D E <br /> 1 i <br />