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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 <br /> Telephone:, 5209) 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 /> i- and/or install the work herein described. This application is made in compliance with Sana <br /> L'caqui n County Ordinance NO 1862 and a Rules and Regulations of the San Joaquin .Local Health <br /> District. `Zz2b0 co) <br /> 4 <br /> EXACT STREET ADDRESS �' CITY/TORN <br /> Owner'-s Name. Phoneme <br /> Cit <br /> Address t! y.:.. <br /> Contractor's Name License# Y/3 Phane� .5 -- <br /> t` IS CERTIFICATE OF WORKMAN IS`1COtAPFNrATIO"! I� SURA�ICE ON FILE WITH SJLHD? YES NO <br /> TYPE OFWORK (Check) : NEW WELL y -1TDEEPEN ElRECONDITION ❑ DESTRUCTION[D <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP J NSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> -DISTANCE TO NEAREST: SEPTIC TANK, �f-SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD�00:T7 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE' DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �S <br /> ` Industrial Cable Tool Dia. of Well Excavation <br /> [Domestic/private Drilled Dia. of Well Casing"WR <br /> Domestic/public Driven - Gauge of Casing 1s/) zo <br /> Irrigation _X. Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection —XRotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : <br /> i <br /> PUMP INSTALLATION: Conti;actor <br /> Type;lof Pump H.P. <br /> PUMP REPLACEMENT: �]State Work Done <br /> t <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 accordant <br /> With San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca- <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 CLk FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> { SIGNED TITLE: DATE: ht2 <br /> DR W PLOT PL N ON REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> � PHASE I � <br /> APPLICATION ACCEPTED BY DATE./— F <br /> , ADDITIONAL COMMENTS : :I" <br /> PHASE II GROUT INSPECTION PHASE TIT FINAL INSPECTION <br /> . INSPECTION BY DATE 2 S 7iF INSPECTION BY DATE <br /> iEH <br /> J7 <br />