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I <br /> ' SAN JOAQUIN10CRL HEALTH DIST'RICT <br /> FFICE USE: 1601 E. Hazelton Ave. ,. Stockton, CA 95205 Permit No. 'Sy <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued '7 ; <br /> 7 <br /> This Permit Expires 1 Year From Date Issued :r <br /> Complete In .Triplicate) <br /> - <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or instal'I 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 SADDRESS Hel-kod kdd CITY/TOWN 1p�� <br /> Owner's Name M rS, �y �/!� -- — Phone- <br /> City_ <br /> Address ' <br /> Contractor' s Name Li ce n se#.34.C7s3;- . Phone S 'f— .3 _ <br /> IS CERTIFICATE OF WORKMAN'S C011PENSATIO`J INSURANCE ON FILE WITH SJLHO? YES mo <br /> i <br /> TYPE OF WORK (Check)f: NEW WELL 0 - DEEPEN 0 RECONDITION [ DEaTRUCTION11 -V <br /> WELL CHLORINATION n WELL ABANDONMENT 0 OTHERMo W <br /> PUMP INSTALLATION K PUMP REPAIR❑ PUMP REPLACEMENT [I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY f� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE. PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC ^ <br /> 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 Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ti—b <br /> PUMP REPLACEMENT: p State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: S4 _____ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION .ACCEPTED BY. DATE _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY rn DATE INSPECTION BY DATE <br /> - -- - - — A/.P9 e, 2,I <br />