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r. SAN JOAQUIN LURAL HtAL!H Uig i KII,l Permit No. �- <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 2 <br /> Telephone (209)466-6781 Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ices 1 Year- From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin 'Local Health Dlstrict .for a permit -to- construct <br /> and/or install the work herein described. This application is made in compliance' with San a- s <br /> ,'oaaui County Ordinance .��o. 1562 and the Rules and Regulations of the San Joaquin. LocalHealth • <br /> District. - <br /> EXACT STREET ADDRESS Y Q CITY�TOWN S97-ne k' <br /> Phone 3/ O el0 <br /> Owner' s Name ' o eu <br /> Address c city <br /> License# Phone„ 3 <br /> Contractor, s Name [�t ►� u -� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? Y£S v NO <br />( TYPE OF WORK {Check} : NEW WELL❑ DEEPEN ElRECONDITION ❑ DESTRUCTION El <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION C7 PUMP REPAIR❑ PUMP REPLACEMENT,. <br /> IDISTANCE TO!;NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPAL FIELD <br /> CESSPOOL/SEEPAGE PI.T_ OTHER <br /> OS <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 �1 <br /> Disposal Other Other Information <br /> Geophysical -Other <br /> Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> il Type of Pump H.P. <br /> ( PUMP REPLACEMENT: [!]-State Work Done v ti d <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 /> 11 WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE: DATE: <br /> SIGNED DR W PLOT L N ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ' ADDITIONAL COMMENTS: A�: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE-.;,-- - 14 <br /> g <br /> - -- 1/78 2M <br />