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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ,. Stockton, CA 95205 Permit No. -Z1!?--y---1:n <br /> Telephone: (209) 466-6781 <br /> Date Issued 7— <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ��i � CITY/TOWN <br /> Owner' s Name Phoned <br /> Address vV C.� Ci ty 2-22 <br /> Contractor' s Name License#- Ve,- G Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELLED DEEPEN 0 RECONDITION C] DESTRUCTION[] <br /> WELL CHLORINATION D WELL ABANDONMENT C7 OTHER 0 <br /> PUMP INSTALLATION 4- PUMP REPAIR 0 PUMP REPLACEMENT [I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> OS <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 Drilled 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 Ins ailed by: <br /> PUMP INSTALLATION: Contractor �l -�`7 <br /> Type of Pump H.P. <br /> PUMP' REPLACEMENT: ,State Work Don <br /> PUMP REPAIR: 0 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Proce ure <br /> I hereby certify that I ' have prepared this application and that the work will be done in accordant <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 FOR A T INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE: DATE_ <br /> R W PLOT PITN— ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE ' <br /> APPLICATION ACCEPTED BY toL. <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSP-ECTION PHASE JJI FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 7 <br /> Pu 1a99 "u i9i9-' 777� - - $ 2M <br />