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FFICE`USE: SAN JOAQUIN LOCAL-. HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. ,-,Stockton, CA 95205 Permit No. <br /> Telephone:. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 461_ <br /> '(cli <br /> Aomplete In Tri cate) <br /> ?i4pplication is hereby made to the San Joaquin Local Health <br /> and/or install the work herein described. This application�fstmade -infor compliance <br /> to construct <br /> ,Joaquin County Ordinance No. !1862 and the Rules and Regulations of the ,S <br /> compl i ante with "San <br /> District• San Joaquin Local Health <br /> ,WCTr-STREET ADDRESS <br /> 'a CITY/TOWN <br /> _owner's Damev i <br /> ° <br /> Address Phone <br /> Contractor's Name ' it Ci.:ty <br /> 401 /—LicensePhone <br /> ,IS CERTIFICATE OF WORKPfiANVS CO";PENSATION iP7SURA"CE ON FILE WITH SJLHD? YES �� <br /> TYPE OF WORK - _�_ .� O. _ I <br /> (Check) : NEW WELL W DEEPEN ❑ RECONDITION DESTRUCTION <br /> WELL CHLORINATION Q `WELL ABANDONMENT Ej ;;OTHER ....,,. <br /> w PUMP INSTALLATION f5/PUMP REPAIRC3 PUMP "REPLACEMENT [� <br /> k <br /> QISTANCE TO NEAREST .=-'-SEPTICiTANK? ��SEWER LINES /4�.I pIT PRI11y� <br /> SEWAGE DISPOSAL FIELD CESSP L/SEEPAGE PIT ` <br /> PROPERTY LI � RIVRTE DOMESTIC WEL nq <br /> IOTHER <br /> INTENDED USE TYPEL--= PUBL C D MESTIC WELL. +`" M <br /> OF WELL ' <br /> Industrial Cable Tool CONSTRUCTION SPECIFICATIONS <br />�:�Domestic/private Dia. of Well Excavation <br /> �i l 1 ed <br /> Domestic/public Dia• of Well Casin <br />�—Irrigation -��Driven Gauge of Casing <br /> Cathodic Protection Gravel Pack Depth of Grout Sea <br /> Di sposa1 -- -otary Type of Grout `. .. . <br /> Geophysical - -__L2 thea Other Information <br /> Surface Seal .Insta ed Dy: <br />,UMP INSTALLATION: Contractor . <br /> _ Type of Pum <br /> pa <br />'UMP REPLACEMENT: _ H• , <br /> Q State Work Done A ; <br />!UMP REPAIR: F <br /> ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materia �an Proceure ApProx--mate Depth .. w <br /> hereby certify that I have prepared this appl.icatio^o a d that the work will b <br /> ith San Joaquin County Ordinances, State Laws-��-andfRu7�es and -Regulations of the-San-Joa uinoLocace <br /> ealth District. <br /> ry Home owner or licensed agent s -si nature.,certifies the following: 9 1 " <br /> "I certify that in the performance of the work for whG this permit is issued, I 'shal'l <br /> not employ any person in such manner as t6becomesubject to Workman's.-Compensation <br /> Taws of California,," . <br /> WILL CALL F R- GROUT- INSPECTION PRIOR TO <br /> GROUTING AND -A'FIN L--INSPECTION. ; <br /> f GNf D i:: � .._ <br /> TITLE: DATE: <br /> DR �PL ON: 111.11,11,111, REVERS IDE <br /> LASE I FOR DE ARTMEPI USE ONLY <br /> PL Ci ATION ACCEPTED BY <br /> DITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECT _:�4 <br /> ION . <br />>PECTION 'BY DATE PHASE III FINAL INSPECTION <br /> 14 26 Rev. 9/7 INSPECTION BY � DATE <br />