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__._.__-. --_._..._ SAN JOARUIN LCAL4EALTH DISTRICT <br /> FFICE USE: E. Hazelton fve. Stockton, CA 95205 Permit No-2L <br /> Telephone: (209) 44 6-6781 <br /> Date Issued 6-/ , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> �. <br /> (tomp1ete In Tri pIi;cate) <br /> Application is hereby made to the San Joaquin Local •Health :District for a permit to construct 11)3 <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 Rq ulationsgof the San .Joaquin Local' Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name Phone <br />. Idd,ress City -� <br /> Contractor's Name LicenseZ?//4_ Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION IPJSURA"•JC£ N FILE WITH SJLHD? YES 0 - <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN OL RECONDITION DESTRUCTION[n, W <br /> Y WELL CHLORINATION E] WELL ABANDONMENT Q OTHER <br /> PUMP INSTALLATION 0 PUMP-REPAIR❑' PUMP REPLACEMENT Q <br />' DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES,; I PIT PRIVY <br /> SEWAGE DISP SAL IELD 1. C SSP <br /> PIT OTHER <br /> PROPERTY LINFI6 RIVA MESTIC WELPUBLIC DOMESTIC WELL <br /> INTENDED 'USE TYPE OF WELL M CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 1+ <br /> Domes�ic/private ' Drilled Dia. of Well Casin <br /> Domestic/public Driven Gauge of Casing VZLL7 _ <br /> Irrigation, Gravel Pack Depth of Grout' . a <br /> v Cathodic'Protection Rotary Type of Grout. •^ <br /> Disposal ' Other. "- T Other Information <br /> i Geophysical Surface Seal Instal e b , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> , PUMP REPLACEMENT: State Work Done <br /> 10UMP REPAIR: O State Work Done s . <br /> DESTRUCTION OF ,WELL: Well Diameter F Approximate Depth <br /> Describe Material anE Procedure <br /> -I hereby certify that I. have prepared -this application and that the work will be done in accordanci <br /> ;with San. Joaquin County Ordinances`, State_ Laws, and 'Rules -and., Regulations of .the San J6aqui•n Local <br /> "Health District. Home owner or licensed agent's signature certifies the following: 4� <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 /> I WILL CALL OR A GRO I P CT RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> -- .� <br /> WRAW <br /> PLOTTEW ON REV Rag SIDE <br /> OR DEP R MEN SE ONLY <br /> ,PHASE I --- - s ' <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTIQN F <br /> INSPECTION BY DATE INSPECTION BY DATEPi �' " <br /> EH ]4 26 Rev. 9/7$ . <br />