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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1 O1 E. Hazelton.Ave.•,'• Stockton, CA 95205 Permit <br /> Telephone: (209) .466-6181 <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 /> o the San Joaquin Local Application �s hereby made t 1 Health` District for a permit to construct <br /> I t <br /> and/or install the work herein .described`. This application is made .in. compliance with San <br /> ,;oanuin County Ordinance 1,o., 1862 and- the.-Rules and Regulations 'of the San- Joaquin' Local Health <br /> Cistr�ct. l f <br /> EXACT STREET ADDRESS / �3 U:� a'' C l�.1 CITY/TOWN <br /> Owner' s Name �. �� ?� mom,—e��S Phoned- 2 : <br /> I Address �j s _ I^r) c 1CL111lev City <br /> Contractor's Name License# Phone <br /> IS CERTIFICATE OF WORKMA S `COMPENSATION INSURANCE OM FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION 1" <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ` <br /> INTENDED USE f TYPE OF WELL L`CONSTRUCTION SPECIFICATIONS N <br /> Industrial Cable Tool Dia. of Well Excavation <br /> --�==Domestic/private =�Dri lTi ed = Di-a-.�of__We11Cas -- <br /> - Domestic/publicDriven - 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 t+ s Surface Seal Instal ed b : <br /> PUMP INSTALLATION: 'Contractor <br /> Yyp kof Pump H.P. <br /> PUMP REPLACEMENT: . State Work Done <br /> r PUMP REPAIR: ❑State Work.rpone <br /> - <br /> DESTRUCTION OF WELL: Well Diameter ...Approxiate Depth <br /> Describe Material and Procedure <br /> F <br /> I hereby certify that I have prepared this application and that the'work will be done in accordar <br /> with San Joaquin County Ordinances, StateTLaws, and - Rules and Regulations of the San Joaquin Locz <br /> Health District. Home owner or licensed agent's signature certifies the following: <br /> I "I certify that in the performance of the work for which this permit is issued, I shall <br /> ilot employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. ". <br /> I WILL CALL JOR R GROUT INSPECTION PRIOR TO GROUTING ANDA FINAL. INSPECTION. <br /> SIGNED TITLE: DATE: P//)V <br /> " <br /> DR W PLOT PL .N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY 6*? I-q W , <br /> PHASE I �� ` `�., ^ } <br /> APPLICATION ACCEPTED BY DATE/47 <br /> ; ADDITIONAL COMMENTS : <br /> PHASE II GROUT� INSPEC ON PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION SY DATE <br /> r � <br /> v21`' <br />