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L)II SAN JOAQUIN LOCAL;HEALTH DISTRICT a <br /> Permit No. <br /> FoR OFFICE USE; 1601 E. Hazelton Ave. , Stockton, CA 95205 - =- - <br /> k Telephone: (209) 466--6781 Date Issued _ 7- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires. l Year From Date Issued <br /> :Compl i: _e I n , -9 plicate <br /> Application is hereby made .to the San Joaquin' Local Health District for a permit to construct <br /> pp lication is made in compliance with San. ! <br /> and/or install the work herein described.' This. app <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the .San Joaquin Lo al Health <br /> 1 <br /> District. _ 1jl <br /> TWIT-OWN . . <br /> EXACT STREET ADDRESS <br /> Phone <br /> Owner' s Name City <br /> Address _ ----------- <br /> Name Li cense#�� Phoned` -- <br /> Contractor s "d0 <br /> IS CERTIFICATE OF ijnnv iAN'S CO"iPENSATI0,1 I"SSURA*dCE OSI FILE 1r1IT44 SJLHD? YES <br /> a <br /> TYPE OF WORK (Check) : NEW WELL UQ DEEPEN El RECONDITION DESTRUCTION F1 <br /> s <br /> WELL CHLORINATION Q WELL ABANDONMENT © OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR p PUMP REPLACEMENT ❑ <br />� f PIT PRIVY_ __ <br /> DISTANCE TO NEAREST: SEPTIC-TANK f SEWER LINE P0aLJ5EEPAGE PIT OTHER -� <br /> SEWAGE DISP�IEL <br /> PROPERTY LINfi�011PRIVA E D MESTIG WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> 4. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> G _Gravel Pack Depth„ o•f�Grout Sea p <br /> Irrigation Type of Grout <br /> Cathodic Protection Rotary <br /> Disposal -rk 7_-Otherss Other InformatI onQ <br /> '� <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> k H.P. <br /> Type of Pump <br /> PUMP°' REPLACEMENT: . ❑State Work Done ._ <br /> PUMP REPAIR: ❑State -Work Done.- <br /> 4- � .y. Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materia an Prace ure <br /> I hereby certify that I have prepared this awPliandiRulesand <br /> andthat <br /> Regulat�onswill <br /> the Sandone <br /> JoaquinoLoca <br /> with San Joaquin County Ordinances , State La , <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.WDrkman' s Compensation <br /> laws of California.” <br /> I WILL CAL FOR A GROUT INS 7I P l TO GROUTING AND A FINAL INSPECTION. t <br /> ' TITLE: DATE:_2_1�4 <br /> SIGNED DR IPLOT PL .N ON REVERSE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ��, . . _ - DATE - <br /> APPLICATION ACCEPTED48Y <br /> ` ADDITIONAL COMMENTS: =PHASE-111 FINAL INSPECTION• <br /> -PHASE -II GROUT INSPECTION DATE <br /> INSPECTION BY DATE INSPECTION BY <br />