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SAN JOAQUIN LOCAL HEALTH DIS-CRICT <br /> FFIGE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7r- <br /> Telephone: (209) 466-6781 <br /> a <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires I. Year From Date Issued fF . <br /> Complete In Triplicate ;�r r <br /> Application is hereby made to the San Joaquin Local Health District for.-a permit to construct, ''µ'4 <br /> and/or install the work herein described. This application - is made in compliance with San <br /> ,'oaq-:in County Ordinance No. 1862- and the Rules and. Re.gula,tions of ,the- San .Joaquin Local Health , <br /> �-�6 <br /> �,.IEXACT STREET ADDRESS �_ izevr,12 6'F � j � -a 4- ITY/TOWN <br /> Owner' s NamePhone 982 <br /> Q.�a12L..a s �L �_tta 1- <br /> Address ^ S_' City Foca L,or�_ <br /> Contractor' s NameLicense# Phone <br /> F , <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO`! INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN 0 RECONDITION ❑ DESTRUCTIONEJ s <br /> WELL CHLORINATION WELL ABANDONMENT p OTHER 0 _ -- <br /> M PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> k <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER K ` <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL -q <br /> INTENDED USE r 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 A Gravel Pack Depth of Grout Seal o <br /> Cathodic Protection Rotary Type of Grout In <br /> Disposal Other Other Information <br /> Geophysical � �rface Seal Installed by: <br /> PUMP INSTALLATION: Contractor �vtapR ie Ne la C��'� of t? <br /> r)4!;eu� aNc­ Type of Pump H.P. i2 5'. <br /> PUMP REPLACEMENT: V []State Work Done <br /> PUMP REPAIR: ❑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 accordanc( <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: <br /> (DRTW PLOT PLAN ON REVERSE SIDE <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ffhf7 <br />° ADDITIONAL COMMENTS: <br /> PHASE I1 GROUT INSPECTION PHASE III INALSPECTki;7ev <br /> �` <br /> INSPECTION BY DATE �/�/ INSPECTION BY DATE ?S <br />