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Ca Ile, SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOR -QFFIC,E USE: 1601., E. Hazelton Ave. , Stockton, CA 95205 EDate <br /> t No. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Issued � (v T F <br /> This Permit Expires 1 Year 'Fram Date Issued <br /> Complete In Triplicate a <br /> Application is hereby made to the San Joaquin Local Health District for a permit -to construct <br /> and/or -install the work herein1described,. . .This .application is made in with San <br /> Joaquin County -Ordinance No. -', 862 -and the Rules and Regulations of the San. Joaquin. Local Health <br /> District. .� ��^^// <br /> CITY/TOWN L11� ��. } <br /> EXACT STREET ADDRESS AA' 4Lar a <br /> Owner's Name ,r 1I Phone <br /> Address , I! M A.1=049:2!t ° . . City g <br /> '26 7L <br /> # Phone 6-k — <br /> Contractor' s Name _ License.--1��.�2�:� � <br /> IS CERTIFICATE OF WORKMIAN'S COMPENSA IO INSURANCE ON FILE WITH SJLHD? YES NO ` <br /> TYPE OF WORK (Check) : NEW. WEIL CI DEEPEN ❑ ~RECONDITION C] DESTRUCTION❑ GL <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR EA PUMP REPLACEMENT ❑ V ; <br /> i <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 /> INTENDEb USE fi TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> }� Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge ©Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> CathodicProtection ,Rotary Type of Grout <br /> Disposal •Other Other Information <br /> Geophysical µ _ Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor . . u <br /> Type of Pump u i H.P. t <br /> PUMP 'REPLACEMENT: ❑State Work Done _ <br /> r <br /> PUMP REPAIR: C.2lstate W6rk Done <br /> DESTRUCTION OF WELL: Well Diameter H 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 /> iHealth 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. " in,, <br /> such <br /> WILL CALL FOR A GROUT INSPECTI IOR 0 GROUTING AND A FINAL INSPECTION. <br /> ITLE: <br /> SIGNED RS DATE: S <br /> ' D W PLOT"PL N ON REVS <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I t <br /> 'TPACCEPTED BY DATE-PLICATION <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION�d <br /> INSPECTION BY DATE INSPECTION BY DATE - 4-M <br /> ICU inOc n— 11) 77 ...,... �. <br /> 2M <br />