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J SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFiCE USE: 1601 E. Hazelton -Ave. ,. <br /> Stockton, CA 95205 Permit No. 2?--ZLk- _ <br /> Telephone: (209) 466-6781 Date Issued _ - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires 1 Year From Date Issued. <br /> Complete In Triplicate <br /> 4' A lication is hereby made to the San Joaquin Local Health District fora permit to construct <br /> pPThis apication isin <br />° and/or install the work herein described. Rules apndlRegulatiansmofethe 5anpJoaqueinwithLocalaHealth <br /> 'oanu�n County -ordinance No. 1862 and the <br /> District. �,/ <br /> EXACT STREET ADDRESS � � -3 a CITYJTOWN <br /> Phone <br /> Owner'sName <br /> .. - City, <br /> Address <br /> { Contractor' s Name <br /> License#.�387_f_ Phone <br /> IS'LLCERT-IFI-CAT-E--.-OF_W0RKMAN'S-COMP£NSAT IO1! .IiaSU:RA110E_ON FILE,-WITH_SJ-HD. YES <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT Q OTHERREPLACEMENT ❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP o(� <br /> DISTANCE TO NEAREST: SEPTIC TANK F SEWER LINES PIT <br /> PRIVYPIT OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/ <br /> PROPERTY LINE -. PRIVATE DOMESTIC 'WELL PUBLIC DOMESTIC WELL <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private <br /> Drilled Dia. of Well Casing <br /> Driven - Gauge of Casing <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> . PUMP REPLACEMENT: ❑ State Work D ne <br /> 4 <br /> } PUMP REPAIR: ❑State Work Done - <br /> - Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I have prepared this application and that the work will be done in accardan <br /> ' I hereby certify that P P <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 following: <br /> I certify that in the performance of the work for which this permit is issued, I shall <br /> 11not employ any person in such manner as to become subject to Workman' s Compensation <br /> 5 laws of California." <br /> I WILL CALL A ROUT I PECTION PRIOR TO GROUTING AND INSPECTION <br /> A FINAL . <br /> SIGNEDDATE: <br /> TITLE: �710 <br /> DR W PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 11)ATE <br /> APPLICATION ACCEPTED BY <br /> [ADDITIONAL COMMENTS : PHASE III' FINAL- INSPECTION <br /> PHASE II GROUT INSPECTION <br /> [INSPECTION BY DATE INSPECTION BY , DATES—' <br />