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FFICE USE: SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> r 1601 E. Hazelton Ave. , Stockton, CA 9 <br /> Telephone: S20S Permit No. y 3 <br /> { p (209) . 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ices 1 Year From: Date Issued <br /> Complete. In Triplicate <br /> Application is hereby made to <br /> and/or the San Joaquin Local <br /> Di /o install the work herein described. This. applilcationDistmade inrict rcomplianceermit twith nSan-- <br /> str in County Ordinance ��o. 18 2 and e Ru7� nd Regulations •of the San Joaquin .Loca1 He <br /> District. �� r73G� M � ' /] � ,� a' th <br /> EXACT STREET ADDRESS <br /> �e <br /> Owner's Name CITY/TOWN <br /> a� <br /> �'li,�► � � , <br /> AddressPhon <br /> L <br /> 00 <br /> Contractor's Name MLCity- o <br /> S ' . LicensPhone <br /> IS CERTIFICATE OF WORKMM4IS COMPENSATIOIN INSURANCE Oil <br /> _ FILE WIT�1 SJLHD? YES NO { <br /> TYPE OF WORK (Check) : NEW WEL O DEEPEN ❑ RECONDITION C) e DESTRUCTION z � <br /> WELL. CHLORINATION C] WELL ABANDONMENT p OTHER ❑ ❑ <br /> PUMP INSTALLATION A . PUMP REPAIR E3 PUMP/RE,PLACEMENT [] x <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT%PRIVY D ° <br /> SEWAGE DISPOSA FL FL IELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL - <br /> Industrial Cable Tool CONSTRUCTION SPECIFICATIONS <br /> Dia: of Well Excavation <br /> Domestic/public I Drilled Dia. of Well Casing <br /> -- Driven - "," Gauge of Casin <br /> `Irrigation -1 Gravel Pack Depth of GroutgSeal <br /> Cathodic Protection Rotary <br /> Disposal Other Type of Grout <br />-----Geophysical + ,Other, Information <br /> Surface Seal Installed b : <br /> UMP INSTALLATION: Contractor <br /> Type of Pump <br />'JMP REPLACEMENT: <br /> []State' Work Done <br /> LMP REPAIR: . <br /> x ❑State Work Donees _ <br /> -TRCTION OF WELL":- 'Well Diameter _ <br /> —Approx-i-mate-Depth—­ <br /> Describe 'Materidl and Procedure' <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br /> th San Joaquin County Ordinances , State Laws ,, and Rules and Regulations of the San Joaquin Local ' <br />�alth 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 /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> GNED TITLE: <br /> DR W PLOT PL N ON REVERS DE s DATE: <br /> 4SE� I FOR D PART ENT USE NL <br />'LIGATION ACCEPTED BY".,;�- �k <br />)ITIONAL 'COMMENTS : <br /> 4 ` DATE <br /> yPHASE II GROUT INSPECTION { <br /> PECTION! BY "s= P SE III FINAL INSPECTION <br /> DATE INSPECTION BY DATE z I <br /> 142.6 Rev. 12-7-7 _ 0 6d_ r�j <br />