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.31 SAN JOAQUIN� LOCAL1HEALTH DISTRICT` <br /> FO FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Tel epho r'e-. . 1-209.) ;466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued . <br /> This Permit Ex ires 1 .Year From Date Issued <br /> Complete In Triplicate . d a <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 incompliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San .Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS3iTY/TORN <br /> Owner's Name edPhone�M- 752- ._ <br /> Address5 qG , --- City I <br /> Contractor's Name ' 1 License# Phone <br /> IS CERTIFICATE OF WORKMAN S COIIIPENURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL ] DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ ' <br /> WELL CHL RINATION Q WELL ABANDONMENT 0 OTHER( <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT ❑ U <br /> DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES PIT PRIVY v, <br /> SEWAGE DISPOSAL FIELDQ! CESSPOOL/SEEPAGE PIT OTHER d <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PLLBLIC 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_ 4; )q �,___ r `' <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection V _Rotary Type of Grout <br /> Disposal Other Other Information —12a ozlxg.4 <br /> Geophysical Surface Seal Instal IR, by:(/ <br /> ` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: (]State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Procedure <br /> I hereby certify that I have prepared this application and that the work will -be done in accordance' <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 NSPECT ON PRIORR GROUTING AND A KNAL INSPECTION. <br /> SIGNED TITLE: _ DATE: o <br /> DR PLOT PION ON REVERS DE <br /> FOR DEPIARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �( DATE/--?/- 7Y- <br /> ADDITIONAL <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHASE IIS INAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ///3—/7J <br /> / / r <br /> A& <br />