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SAN JOAQUIN LOCAL HEALTH DISTRRIC�5205 Permit No. 4- ?6Fog '7 <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, <br /> CA Telephone: (209) 466-6781 Date Issued ( - *7-77 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Tqis Permit. Ex fres 1 Year From Date Issued <br /> Complete. In Triplicate <br /> Local Health District-for a permit to construct ' <br /> Application is hereby made tolithe San Joaquin L in compliance with San +� <br /> PP lication is made P <br /> and/or install .the work herein described. This .and <br /> Joaquin County ,Ordinance No..�1862 and the -Rules .and Regulations of the San Joaquin Local Heal I <br />` wistrict• CITY/TOWN <br /> EXACT. STREET ADDRESS, Phon ! <br /> Owner's Name /S � ` <br /> City <br />' Address - M Phone <br /> ' Contractor' s Name- <br /> License# <br /> t IS CERTIFICATE OF LdORKt1Af!'S CO"1PENSATIO',1 INSURAIN E ON FILE WI.THS 5J1 144? YES <br /> NO <br /> TYPE. OF WORK {Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ 1% DESTRUCTION❑ � <br /> WELL 'CHLORINATION Q WELL ABANDONMENT ❑ OTHER <br /> ' PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE' TYPE OF WELL CONSTRUCT�I'ON 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 /> Gravel Pack Depth of Grout Seal <br /> Irrigation _ Te of Grout <br /> j Cathodic Protection {� Rotary _.Other -Information <br /> ° ; <br /> Disposal Other <br /> Geophysical II Surface Seal Installed b <br /> fPUMP� INSTALLATION: Contractor P <br /> -------- <br /> Type of Pump <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: WelliDiameter rApproximate Depth <br /> Describe Materia an Procedure <br /> .I hereby certify .that I have prepared this application;. an.d that- the work-will be done in accordan <br /> " with San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Loca <br /> Health District. Home owner or licensed-agent' s signature certifies the follow g: <br /> "I certify that in the performance of the work for which this permit is issI shall <br /> not employ any person in such manner as to become subject to Workman's Cam ation <br /> laws of California." <br /> iI WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A_ FINAL INSPECTION. <br /> SIGNED - <br /> ' TITLE: DATE: <br /> DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEP ENT USE ONLY <br /> ` PHASE I DATE `ZS�� <br /> APPLICATION ACCEPTED B <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION BY C <br /> ATE <br /> t 8 2 <br />