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SAN JOAQUIN LOCAL 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 �° 7 <br /> This Permit Expires 1 Year From Date Issued <br /> C&nplete 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 and the Rules..and Regulations of the San Joaquin Local Health <br /> District. i <br /> EXACT STREET ADDRESS ,S CITY/TOWN_,i� , 6,,, <br /> Owner's Name Phone <br /> Address City onr <br /> Contractor' s Name License Phone - el/10 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO?! I'NSURANCE ON FILE WITH SJLHD? YES 11,40 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN EI RECONDITION JE DESTRUCTION d 13' <br /> s <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 _ N <br /> PUMP INSTALLATION C1 PUMP REPAIR❑ PUMP REPLACEMENT C9 <br /> J <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL t FIELD —CESSPOOL/SEEPAGE PIT —, OTHER <br /> PROPERTY LINW .IPRIVATE DOMESTIC WELD� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation /� ' �rac�s i.uw_rv / <br /> Domestic/private Drilled Dia. of Well Casing - � er - Vi <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : GvWA_v� � -70 <br /> PUMP INSTALLATION: Contractor H.P. Al <br /> Type of Pump �� L <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br />, with San Joaquin County 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 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 CAL FOR A GR T INSVVCTIO P TO GROUTING AND A FINAL INSPECTION. <br />€ SIGNE TITLE: DATE: <br /> �DRAT LAN ON REVER IDE <br /> j FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 4 -7- <br />� ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE �' INSPECTION BYGt•i°f DATE 0-0- <br /> 7 <br /> 2M <br />