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SAN QAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Haze ,ton Ave. , Stockton, CA 95205 Permit No.'1-7 9 <br /> Telephone: (209) 466-6781 Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires 1 Year From Date Issued. 2 oG 1 <br /> / 9 i Complete In Triplicate <br /> Application is hereby made to,� the San Joaquin Local° Hea-lth District for a permit to construct <br /> c Y <br /> and/or install the work here-in described. This application is made in compliance with San <br />� 'oaqu�n County Ordinance No. +1862 and the Rules and Regulations 'of the San Joaquin Local Health <br /> District- �1 w <br /> EXACT STREET ADDRESS / CITY/TOWN <br /> Owner' s Name Phone <br /> Address:. . 70 <br /> City. z�G <br /> Contractor's Name License# Phone <br /> �. Z— NO <br /> IS CERTIFICATE OF WORKMAN"S CO!4A�=ION I�dSURA��CE 0�! FILE l�lITH SJLHD. YES <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> �I <br /> WELL CHLORINATION C3 WELL ABANDONMENT E3OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINESt-A)d PIT PRIVY ,� ` 71 <br /> SEWAGE DISPO AL FIEL r CESSPOOL/S PA E ITS---OTHER <br /> ' PROPERTY L1 �RiVAT�OMESTIC WELL/� PUBLIC DOMESTIC WELL <br /> r INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , Cable Tool Dia. of Well Excavation <br /> Domestic/private I <br /> Drilled Dia. of Well Casing 5 ' <br /> Domestic/public FI Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ` <br /> Cathodic Protection _ C�Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> IPUMP INSTALLATION: Contractor I <br /> y P. <br /> Type of Pump H. <br /> jPUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> , DESTRUCTION OF WELL: WellIDiameter Approximate Depth <br /> Desc ibe Material and Procedure <br /> � I hereby certify that I have prepared. this application and that the work will ,be done in.accordan <br /> -- with San Joaquin County Ordinances , State Laws , and Rules and 'Regulations-of the San„Joaquin Loca <br /> Health District. Home owner, or'licensed agent' s signature certifies theme following•" r <br /> "I certify that in the performance of the work, for which this pe'rmit,lis 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 LL FORA G OUT JNSPEC TION PRIOR TO GROUTING AND A FINAL INSPECTION. ,/- <br /> ' TITLE: DATE: <br /> E SIGNED — - <br /> DR W PLOT PLAN ON REVERSE SIDE) <br /> { FOR . EPARTMENT USE-- ONLY <br /> PHASE I DATE 2 <br /> r PPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION' PHASE III FINAL INSPECTION <br /> 1INSPECTION BY DATE 7 INSPECTION BY- <br /> Q8 "� <br /> 8 y- 178 rR 1 f <br /> 21'J <br />