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SAN JOAQUIN LOCAL HEALtH DIS ! R10' <br /> FFICE USE: 1601 E. Hazelton- Ave. ,..Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued + <br /> This Permit Expires 1 Year From Date �Issued <br /> Complete In Triplicate <br /> Application 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 /> Joaquin County-Ordinance No. 1862 and the Rules an-d Regulations of the San Joaquin Local Health <br /> District. <br /> r <br /> EXACT STREET ADDRESS U 3b r 77. ,- T� CITY/TOWN <br /> Owner's Name - � ` ' - Phone_ <br /> Address ` O C� '77 City <br /> Contractor's Name.. . - �,r.� / Li cense (a Phone -3 <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATIO'N Ii1SURANCE ON FILE WITH SJLHD? YES --- NO <br /> TYPE' OF WORK (Check) : NEW WEI:L_0 DEEPEN ❑ RECONDITION [3 DESTRUCTIONE3 <br /> WELL CHLORINATION 0 WELL ABANDONMENT C OTHER 0 � <br /> PUMP INSTALLATION Cl PUMP REPAIR, - PUMP REPLACEMENT Q O <br /> • � 9 <br /> DISTANCE TO..NEAREST:___-SEPT-I-C—TANK ...SEWER--LINES = - - -PIT- PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ` <br /> INTENDED USE 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 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other "` Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor. <br /> Type of Pump H.P. /Q <br /> PUMP REPLACEMENT: ❑State Work Done _ <br /> PUMP REPAIR: ark Done: <br /> -State W <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material ,and Procedure <br /> I hereby certify that I ',hame prepared this application and that the work will be done in accordancE <br /> with San Joaquin County Ordinance`s , State. Laws , and Rules and Regulations of the San Joaquin Local . <br /> Hea l th_D-ist-ri-ct,- --Home--owner-orrl i-censed. agent' s- signature certi fi-es 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 suchmanner as to become subject to Workman 's Compensation <br /> laws of California. " <br /> I WILL CALL FO G OUT INSP TION PRIOR GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: �Z <br /> ' DR W PLOT PLA ON REVERSE/SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ?' DATE q.,2 2,2 <br />