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SAN JOAQUIN LOCAL HEALI H DISI RiL l ' <br /> OFFICE US'E: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> Telephone: (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 ' <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 /> Joaquin County Ordinance No. 1862. and the Rules .and Regulations of the-San Joaquin Local Health <br /> District. <br /> EXACT -STREET ADDRESS�.2 -, �C �r-� 14n114>+.> +C r�aj,j L-one ITY/TOWN Tr c <br /> Owner's Name _ _ P�,.I'��-v Phone_ 5 <br /> Address = 1111 sCity 4 ., <br /> Contractor' s Name Q�T , ������,.�,,,C.�,,� License# Phoney, <br /> IS CERTIFICATE OF WORKMAN'S CO'"PENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> f <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN El RECONDITION 0 DESTRUCTION( <br /> - WELL" CHLORINATION Q WELL ABANDONMENT .0 . ' OTHER 0 <br /> PUMP IN ' -,PUMP REPAIR p.. ." PUMP REPLACEMENT—Q., <br /> DISTANCE TO NEAREST: SEPTIC TANK - - +SEWER, LI-NES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD .,` CESSPOOL/SEEPAGE PIT OTHER ►L <br /> PROPERTY LINE,.-. PRIVArE-ZOMEST"IC WELL1_Zj_-:�.--__PUBLIC DOMESTIC WELL_ <br /> ry � <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 r <br /> Irrigation Gravel Pack Depth; of Grout Seal A-4 <br /> Cathodic Protection.` Rotary Type of Grout <br /> Disposal Other Other4lnformation <br /> Geophysical Surface Seal Installed by: a <br /> PUMP INSTALLATION: Contractor C,l <br /> Type of Pump - -�, H.P. <br /> i Y� <br /> PUMP REPLACEMENT: El State Work Done I r <br /> PUMP REPAIR: Q State Work Done l <br /> DESTRUCTION OF WELL: Well Diameter " Approximate Depth <br /> Describe Material an - Proce ure , <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 workf6r-idhi.eli 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 INSP TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED r TITLE:-444 f DATE: <br /> DRAW PLT PLAN ON REVE7RSE SIDE) <br /> FOR DEPARTMEIWT USE ONLY <br /> PHASE I �--- <br /> APPLICATION ACCEPTED BY DATE J <br /> ADDITIONAL COMMENTS : <br /> PHASE, I GROUT INSPECTION PHAS III F NAL INSPECTION <br /> INSPECTION BY �` � DATE . — -a 7 INSPECTION B DATE 3a <br /> ri . •nom- .� ... ..+. - I" Ills <br />