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C SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> l-rICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. `7 SSG 7i <br /> �J Telephone: (209) -466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �� <br /> This Permit Expires 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 <br /> and/or install the work herein described. This application is made in compliance with. San <br /> Joaquin County Ordinance No. 1862 d. the Rules and Regulations of the. San Joaquin Local Health <br /> District. �2�'I/ Gtl <br /> EXACT STREET ADDRESS CITY/TOW <br /> Owner' s Name Phone,//- <br /> Address <br /> hone/Address Ci <br /> Contractor's Name License# one <br /> r <br /> IS CERTIFICATE OF WORKf1AN nMPENSATIO"J INSURANCE ON FILE WITH SJLHD. YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ ESTRUCTION M <br /> WELL CHLORINATION d WELL "ABANDONMENT OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ UMP REPLACEMENT ❑ ,p) <br /> DISTANCE TO NEAREST:�E,._ SEPTIC TANKgpAe SEWER 'LINES IT PRIVY fi <br /> SEWAGE DISPOSAL FIELDCESSPO /SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DO ESTIC ELL PUBLIC DOMESTIC WELL <br /> INTENDED"USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �, <br /> Industrial Cable Tool Dia. of Well Excavation ,?yl <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publ" Driven 'Gauge of Casing I� <br /> �I rri pati oni �'/���, _ (�Grav 1 Pack Depth of Grout Seal <br /> Cathodic Prot ction _ C Rot Type of Grout <br /> Disposal �-0th r 0 , er Information <br /> Geophysical urface Seal Installed b : <br /> PUMP INSTALLATION: Contractor <br /> Type of4ek <br /> H. j <br /> PUMP REPLACEMENT: Q State ' <br /> PUMP REPAIR: ❑State <br /> DESTRUCTION OF WELL: Welli Approximate Depth <br /> Des r' and Procedure <br /> i <br /> I hereby certify that I ve prepar this application and that the work will be done in accordance <br /> with San Joaquin Count Ordinances State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Ho owner or I 'censed agent' s signature certifies the following: i1 <br /> "I certify that the perfo nce 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." i <br /> I WILL CALt FOR A GROJn INSP-ECTION PV13R TO GROUTING AND A FbNAL INSPECTION. <br /> SIGNED TITLE - DATE: . . <br /> DR W PL T N ON REVERSES E <br /> FORD ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY OC( c,e .- �J . „'; DATE �(�a <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> -7- Z3_ <br /> v � <br /> CLI l AOC' nom.. It 11 <br />