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SAN JOAQUIN LOCAL .HEALTH U15IRiCi Permit:No.1601 E. Hazelton Ave. ,. Stockton, CA 95205 <br /> Te}ephone: (209) 466-6781Date Id 7—/ -2 <br /> APPLICATION FOR WELL CONSTRUCTION QR PUMP PERMIT <br /> This'Permit Ex ices '1 Year From.Date Issued , <br /> Complete In Triplicate <br /> San Joa uin Local Health District for a permit <br /> nCetwithnSanuct <br /> Application is hereby made to the Sa q lication ismade in compliance <br /> and/or install the work herein described. This app <br /> Ordinance- No. J8 62 and the Rules and Regulations of the San Joaquin Local Health <br /> Joaquin County Ord <br /> District. // / CITYITOWN <br /> D R S (D l? 'e <br /> EXACT STREET AD Phone <br /> Owner's Nam//e City. -� <br /> Address (a _ License#r� Phone <br />: Contractor's Name <br /> •� t "1PENSATIO?! INSURA'dCE ON FILE 1r1IT11 SJLHD? YES <br /> IS CERTIFICATE OF I,ORK�1Asd S CD DESTRUCTION[] <br /> TYPE' OF WORK (Check) : NEW WELL G DEEPEN Cl WE <br /> WELL <br /> OTHERI� <br /> WELL CHLORINATION PUMP REPLACEMENT 'S <br /> x � PUMP INSTALLATI0 PUMP 'REPAIR❑ <br /> PIT 'PRIVY <br /> DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES PIT <br /> PIT OTHER <e� <br /> SEWAGE DISpDSAL :FiELD�� PUBLIC DOMESTIC WELT= <br /> -- <br /> PROPERTY LINE PRIVATE DOMESTIC WELL O RUCTION SPECIFICATIONS <br /> i': f TYPE OF WELL <br /> INTENDED USE 4 Cable Tool Dia. of Well Excavation <br /> Dia. of_Wel� 1 Casing <br /> Industrial Drilled <br /> Domestic/private � . - . . Gauge of Cass ng <br /> Domestic/public Driven t <br /> 7_ -Gravel... Pack �.- Depth.-of.Grout Seal-- <br /> Irrigation — Type of Grout <br /> € Cathodic Protection Rotary <br /> Other Other Information <br /> E Disposal --- S rface Seal Installed b <br /> Geophysical , <br /> PUMPIAL <br /> NSTLATION: Contracto ' H.P. <br /> Type'-of Pump <br /> 0State Work Don <br /> PUMP REPLACEMENT: P ,I <br /> State Work Done <br /> PUMP REPAIR: Q , Approximate Depth_Z_ <br /> k <br /> DESTRUCTION OF WELL: Well Diameter _ . - <br /> Describe Materia an Proce ure <br /> klication and that the work will be done in accorda <br /> 1I hereby certify that I have prepared this app <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loc <br /> Health District. Home owner or licensed agent's signature <br /> ratureh thiscertifpermities eisoissued, I shall <br /> "I certify that in the performance <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> f laws of California." <br /> I WILL CAL FOR A G INSPECTION PRIOR TO GROUTING AND A. FINAL INSPECTION• DATE: <br /> TITLE: <br /> "SIGNED DRAW PL T PL N ON REVERSE SIDE <br /> _ <br /> FOR DEP R7MENT USE ONLY , : x <br /> PHASE-1 <br /> f <br /> - DATE -- <br /> APPLICATION ACCEPTED BY ' <br /> ADDITIONAL COMMENTS: I PHASE. II FINAL INSPECTION <br /> PHASE II GROUT IN ECTION DATE <br /> INSPECTION BY <br /> DATE INSPECTION BY <br />