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SAN JOAQUIN LUC'AL HEALTH UlSIKiUI Permit No. - <br /> EQR FFICE USE: 1601 E. Hazelton Ave. , ,Stockton, CA 95205 <br /> Telephone: (20.9)_ 466-6781 Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit ,Ex ires 1 Year. F.rom Date Issued <br /> Complete In Triplicate - , <br /> Aoplication 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 /> , oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> 'istrict. - <br /> '� CITY/TOWN <br /> EXACT STREET ADDRESS <br /> ,� � Phone ���' ;2101 �. <br /> Owner's Name F <br /> t City <br /> Address <br /> Contractor' s Name — Licenseg2 jp one p2.Za <br /> IS CERTIFICATE OF WORKMAN'S COM'PENSATIO'N I'1SURA110E ON FILE WITH SJLHD? YES NO <br /> L _��. -v^r'•'_. A w_��.T.-- a .,_. -�� `- ��..i._ <br /> TYPE OF 14ORK. Check) : NEW WELL C} DEEPEN ❑ RECONDITION ❑ DESTRt1CTI0N� _J Ln� , <br /> — WELL CHLORINATION L7 WELL.PUMP �REPApNT S <br /> OTHER F-3 <br /> R�k MP REPLACEMENT Q . <br /> PUMP INSTALLATION ❑ <br /> PIT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> CESSPOOL/SEEPAGEYPIT OTHER <br /> SEWAGE DISPOSAL FIELD <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , Cable Tool Dia. of Well Excavation <br /> Domestic/private 1 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 /> k Geophysical _ Surface Seal Instal ed b <br /> 1 <br />{ PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: r]State Work Done <br /> PUMP REPAIR: (State Work._Done_ 60D. <br /> DESTRUCTIONOFWELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure <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 persdn in such manner as to become subject to Workman' s Compensation <br /> laws of California." <br /> I WILL CALL YOR A GROUT LKPEC ON PRIOR TO GROUTING AND A NA INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DR W PL T PL N ON REVER E SIDE <br /> FOR DE ART ENU E ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE iI GROUT.tINSP£CTION PHASE III INAL INSPECTION <br /> INSPECTION BY IDAT£ INSPECTION BYG✓ DATE?— <br /> I. P1 r7 82 <br />