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f SAN JOAQUIN .LOCAL: HEALTH DISTRICT <br /> FFIC£ SE: 1601 E. Hazelton Ave. , Stockton, CA 95205 LDate <br /> Issued <br /> Permit <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> - <br /> This - Permit Ex ires 1 Year From Date .Issued <br /> Complete In Triplicate <br /> Application is her 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 /> ,oanu;n County Ord _nan.ce No. 1862 and the Rules and Regulations- of the�Sa�+ Joaquin. Local Health <br /> District <br /> EXACT .STREET ADDRESS. <br /> CITY/TOWN f8-l_ OLto --C?/ <br /> Owner' s Name -'d-�' Phone <br /> Address ' � :0 � 6 6? �<<� <br /> Contractor' s Name 4-, Li cense#L ?7;-j Phone z— G"?-� <br /> 9 I>p <br /> IS CERTIFICATE OF WORKMAN'S MPENSATIO'N INSURA"SCE 'ON FILE WITH SJLHD? <br /> �Iv <br />( TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION <br /> L-3DESTRUCT❑N❑ "V <br /> WELL CHLORINATION C] WELL ABANDONMENT <br /> PUMP INSTALLATION ❑ PUMP REPAIR[ PUMP REPLACEMENT ❑ <br /> IDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. ofWell Excavation <br /> Domestic/private Drilled Dia. of Well Casing_ <br /> Domestic/public Driven ,,:s. - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> ti . Cathodic Protection " .Rotary Type of Grout <br /> ►' Disposal . Other r Other Information <br /> Geophysical - Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor - ". H <br /> Type of Pump <br /> PUMP REPLACEMENT: - ]State Work Done +, <br /> G PUMP REPAIR: [State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter r �, <br /> . Describe Material and Pr�`ocedure <br /> I hereby certify that I have prepared this application �dnd that the work will be done in accordant <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 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 FOR A GROUT INSPE T N R TO GROUTING AND A FINAL INSPECTION. _ <br /> SIGNED �'� TLE: Vc-r DATE: 7 s <br /> DRA PL�Tltp4LN REVERSE SIDE <br /> r FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY . . <br /> `ADDITIONAL COMMENTS: <br /> PHASE �I��UTI)NSP.ECTION PHASE III FINAL INSPECTION <br /> ,INSPECTION BY TE INSPECTION BY_ <br /> DATE <br /> ..2M <br /> 'ru IA)c '. o.... X7_77 <br />