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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r`FFICE USE: 1601 E. Hazelton Ave.., Stockton, CA 95205 Permit <br /> j Telephone (209) 4.66-6781 <br /> APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires I Year From Date Issued I <br /> Complete in Triplicate) s <br /> Application is hereby made to ithe San Joaquin °Local. Health District for permit to construct <br /> and/or install the work herein described. : This .applic.ation is made in compliance with San . <br />,oan.fin .County- Ordinance "Yo- 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> DiStr�c4- Y <br /> EXACT STREET ADDRESS <br /> CITY/TOWN <br /> Owner' s NameI° - � <br /> Phone 0 � <br /> Address '02. 0 City <br /> Contractor' s Name LicensWE Phone J d Z / <br /> i <br /> IS CERTIFICATE OF WOnKI`3ArJ`S COMPENSATION INSURANCE -ON FILE WITH .SJLHD? YES Z, to F <br /> TYPE OF WORK (Check) : NEW WELL <br /> -DEEPEfV-C1 "' RECONDITION ❑ - � DESTRUCTION E] <br /> WELL CHLORINATION 0 WELL-vABANDONMENT Q OTHER 0 d � <br /> .PUMP,.INSTALLA7ION 93�FUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK `1 f- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIUATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE + TYPE OF WELL CONSTRUCTION SRECIFICATIONS <br /> Industrial 1 Cable Tool Dia. of Wel] Excavation <br />�_ CDomestic/private ` t Drilled Dia. of Well Casing <br /> Domestic/public r r ' Driven Gauge of Casing <br /> Irrigation tt , Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 'Rotary Type of Grout <br /> Disposal TOther Other Information <br /> Geophysical Surface Seal Installed b : _- <br />'UMP INSTALLATION: Contractor !' � �.F , <br /> Type of Pump <br /> H.P. <br />'UMP REPLACEMENT: ❑State Work Done k <br />'UMP REPAIR: ❑State Work Done . <br /> 1ESTRUCTION OF WELL: We-fl- Diameter '*' Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I 'have prepared this application -and that the work will be done in accordance <br /> lith San Joaquin County Ordinances , State Laws, and Rules and, Regulations of the-San Joaquin Local � <br /> ealth District. Home owner or •licensed=agent' s signature`ce�rtifies the following: ; <br /> "I certify that in the performance of the work for which th'isxpermit is issued, I shall <br /> not employ any person in such manner as to become subjIect to Workman's Compensation <br /> laws of California." x1z .< <br /> WILL CALL FOR A GROUT INSPECT,I-ON.PRIOR .TO GROUT._ING..AND A FINAL INSPECTION. <br /> TLE • <br /> IGNED TI <br /> , DATE: 1 <br /> �(DR�-PLQT�.PL .N ON REVERSE SIDE <br /> RASE I -FOR .,DEPAR.TMFNT USE ONLY <br /> PPLICATION ACCEPTED BY 11 . <br /> DDITIONAL COMMENTS: _t�_/f/�� <br /> DATE <br /> PHASE II GROUT INSPECTI N y <br /> iSPECTION BY -i1-�1 9 .DATE -111 f` P1HASE II FINAL INSPECTION <br /> INSPECTION BY DATE �_�b�11 <br /> 1 1426 _ Rev. 12-77,-a3 kWjjM_ <br />