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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P�j�EFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 'Permit No. ��0- <br /> Telephone: (209) 466-6781 <br /> �----- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3-16 J <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate) 'hl ,� '��/�-f -,— <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 />.'oaau,i n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> uistrct. <br /> EXACT STREET ADDRESS Sia 5 1�✓�efa CITY/TO <br /> Owner' s Nave ,g ,q A/ Phone 3 ff-14c� o <br /> Address City <br /> Contractor's Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO11 INSURAINCE ON FILE WITH SJLHD? YES ;d0 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION DESTRUCTION n <br /> WELL CHLORINATION WELL ABANDONMENT OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ P REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES S� PIT PRIVY � _ A <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 b : <br /> PUMP INSTALLATION: Contractor (� <br /> Type of Pump s H.P. <br /> PUMP REPLACEMENT: [I State Work Done <br /> PU Q State Work Done <br /> ESTRUCTION OF WELL- Well Diameter Appr ximate Depth <br /> Describe Materia and Proced rea--v _ <br /> �-. <br /> I hereby certify that I have prepared this application and that the work will be done7"nVacFordance <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 /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO- GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 3 - /:3 <br /> DR W PLOT PLTN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />)HASE I <br /> APPLICATION ACCEPTED BY DATE .3/ ?_ 7 <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PS" I FINAL INSPECTION <br />;NSPECTION BY DATE /19- INSPECTION DATE�H- 1426 Rpy- 12-77 - o <br /> - l�A <br />