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i µ "SAN JOAQUIN LOCAL HEALTH DISTRICT — <br /> FOR Ff-INCE USE: � 1601 E. Hazelton Ave. , <br /> Stockton, CA 95205 ; Permit No. 'J - � F <br /> �. Telephone: (209) 466-6781 i <br /> _ V�,� Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT- ., <br /> This Permit. Ex fres 1 .Year From Date Issued`.' <br /> Complete In Triplicate g <br /> Application is hereby made to ;the San Joaquin Local Health -District for a, Permit to construct <br /> and/or install the ,woek herein described. This application is made in compliance with �San <br />,'oaqui n County Ordinance No-. 18/62 and the Rules and Regulations of the San Joaquin Local Health <br /> District. M W GJ S <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner' s Name t s aS Phone °/i <br /> Address A cl ) nC7 L �" City .. <br /> Contractor's Name incense# Q�l _Phor%e <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE OM FILE WITH SJLHD? YES NO <br /> TYPE'"OF WORlC`(Check)N NEW WELL � DEEP IV L7�:�R NDITION�[3 DESTRUC7ION(� J' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT p OTHER 0 � <br /> PUMP INSTALLATION C . PUMP REPAIR❑ PUMP REPLACEMENT ❑ V B <br /> DISTANCE TO NEAREST: SEPTIC TANK/ Mr�-SEWER LTN S ;-JVLIT PRIVY <br /> SEWAGE �DISPOSAL FIELDI /,*, CESSPOOL/SEEPAGE PIT OTHER"IICATIINS <br /> PROPERTY LINE --. PRIVA DOMESTIC WELL, -�- PUBLIC DOMESTCONSTRUCTTOfV SPECIINTENDED USE— �-_ TYPE OF-WELL <br /> Industrial Cable "Tool Dia. of Well Excavation <br /> Domestic/private Drilled - Dia. of Well CasingtL <br /> Domestic/publ i c Driven- - Gauge of Casing �� o-r— <br /> i � Irrigation Gravel° Pack Depth of Grout Seal <br />' Cathodic Protection _ X Rotary` Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed b D n1Fs2 <br />[ PUMP INSTALLATION: Contractor ' -�r ,r,� <br /> Type of Pump fi / �- H.P. 20 <br /> PUMP REPLACEMENT: State Work Done //� �o e, ,�1&.d /Z <br /> 1 PUMP REPAIR: QState Work Done ' <br /> DESTRUCTION=OF=WEL-L . Wel l Diameters APproximat•e-Depth.-- '""F <br /> Describe Material and, Rroce .u`r.e i <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."' t. <br /> _ - .._„•�- 4. ,Y...� -- <br /> I WILL CALL F _- 4UTTTON PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED { TITLE.: DATE: � � f <br /> DRAW PLOT PL N ON REVERSE SIDE <br /> FO DEPARTMENT . E ONLY / 7 <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE TTI FINAL INSPECTION <br /> JINSPECTION BY DATE INSPECTION BYE DATE CI l-7f <br />