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SAN JOAQUIN ,LOCAL HEALTH D1S-rRICT - i <br /> JOR 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 ?- _ <br /> This Permit Ex 'ires 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 /> 'oaquin County Ordinance No. 1862 and thie .Rules and Regulations of the San Joaquin- ,Local Health , <br /> District. <br /> EXACT STREET ADDRESS ` .pCITY/TOWN ,6SC,9Lj,' <br /> Owner' s Name 06,.j 'Phone 3 -� <br /> Address 5'R v„ City C <br /> Contractor' s Name a SL12 Li cense#,,?2!22/o PhoneAW-412d,7'-_ _ • <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION iNSURAINCE ON FILE WITH SJLHD? YES ;JO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION [] DESTRUCTION❑ _ <br /> WELL CHLORINATION C3 WELL ABANDONMENT Q OTHER _ <br /> PUMP INSTALLATIONIM PUMP REPAIRCY- PUMP. REPLACEMENT [] Q <br /> DISTANCE TO NEARLST: SEPTIC TANK SEWER LINES Pd T: PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER--- <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilledi 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 <br /> Geophysical Surface Seal Installed by: <br />' PUMP INSTALLATION: Contractor `7 - -- ---_. <br /> Type of Pump ' --- <br /> PUMP REPLACEMENT: r]State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> k Describe Material an2 Procedure <br /> F <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 CALL OR A OU2 INSPECTION PRIOR TO GROUTING AND A FI AL INSPECTION. <br /> SIGNED TITLE: DATE:=DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEP RTM T USE ONLY <br />: PHASE I <br /> APPLICATION ACCEPTED BY � DATE ? <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION' PHASE III JINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION Bjri DATE /7 <br /> ,7sz 1)M <br />