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UIN <br /> HEALTH <br /> FFICE USE: 1601 EANHazelton Ave- ,OStockton, CA <br /> 5205 Permit No. <br /> I Telephone: . (209) 466-6781 <br /> r <br /> APPLICATION FOR- WELL CONSTRUCTION OR PUMP PERMIT Date Issued { <br /> This Permit Ex ires 1 Year From. Date Issued <br /> Complete .Ire Triplicate. <br /> Application is hereby made tothe San Joaquin Local Health Dist <br /> rict <br /> and/or install. the work herein described. This application- ismade inrca permit to construct <br /> Joaquin County Ordinance No. 1.862 and the Rules and .Regulations of the compliance <br /> with <br /> ocal Health <br /> District. <br /> EXACT STREET ADDRESS ' ' <br /> D CITY/TOWN . G ;. <br /> Owner's Name _ <br /> Address Phone <br /> � / u <br /> C i ty <I-z <br /> Contractor's Name License# 3 `Phone <br /> IS CERTIFICATE OF WORKMAN'S C $ 10P! TPJc,11PAmri ON FILE WITH 5JLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN 0 RECONDITION <br /> WELL CHLORINRTION ® DESTRUCTION�j <br /> OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIDRCO NT PUMP REPLACEMENT <br /> EJ <br /> �l <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CTSSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL r� <br /> INTENDED USE TYPE OF WELLa <br /> Industrial . ell CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of WExcavation <br /> Domestic/private i 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 t <br /> Geophysical Surface Seal Instal ed b : I <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump b H.P. ty� <br /> SUMP REPLACEMENT: M Statek Work Done <br />'UMP REPAIR: State Work Done } <br />)ESTRUCTION OF WELL: Well Diameter <br /> Describe Materia an Procedure <br /> Approximate Depth <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 /> lealth 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." i <br /> WILL CALL FOR A GROUT INSPECT �N PRI-O TO. GROUTING AND A FINAL INSPECTION. i <br /> IGNED. <br /> - TLE: DATE: 6� <br /> W PL T PL� N REVERSE SIDE <br /> JASE I FOR DEPARTMENT USE ONLY <br /> TPLICATION ACCEPTED BY <br />)DITIONAL COMMENTS: , '" OS, DATE�Le4 <br /> 7 /7g <br /> PHASE II GROUT INSPECTIO <br /> JSPECTION BY PHASE III FINAL INSPECTION <br /> DATE INSPECTION BY DATE /z <br /> 11426 Rpm__J2_-77 r� <br />