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�. SAN JOAQUIN LOCAL -,HEALTH DISTRICT' <br /> FF-ICE USE: 1601 E. Hazelton Ave.. ; Stockton, CA 95205 Permit No.����� <br /> Telephone: (209) 466-6781 '. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued, _ <br /> This Permit Expires I Year From Date Issued <br /> Complete In Triplicate r <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 /> k.'oanuin County Ordinance No. 1862 and the Rules and Regulations of the .San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS,. �� g . , "' ,� ,�,' CITY/TOWN <br /> Owner's Name .� Phones.-- P-1, ?7 <br /> Address 4. City <br /> Contractor's Name License# Phone <br /> IS CERTIFICATE.OF WORKMAN'S COMPENSATIO`! INSURANCE ON FILE WITH SJLHD? YES ;10 <br /> _ f <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN Q - RECONDITION ® DESTRUCTION O <br /> WELL -CHLORINATION Q WELL ABANDONMENT IM OTHER 0 <br /> PUMP INSTALLATION ® PUMP REPAIR p PUMP REPLACEMENT E] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavations <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 'Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout , <br /> Disposal Other Other Information } <br /> Geophysical Surface Seal Installed by: <br />'UMP INSTALLATION: Contractor <br /> t <br /> Type of Pump H.P. <br />'UMP REPLACEMENT: ❑State Work Done <br /> SUMP REPAIR: O State Work Done F <br />)ESTRUCTION OF WELL: Well Diameter Approximate Depth r, p� <br /> Describe Material an2 Procedure - - - <br /> f hereby certify that I have prepared this application and that the work will be done in accordance <br /> I th San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local <br /> lealth District. Home owner or licensed agent's signature certifies the following: ; ,4: <br /> "I certify that in the performance of the work for which this permit is issued, I shah <br /> -not employ any person in such manner as to become subject to Workman's Compensation <br /> -k1aws of California. " <br /> WI:LL�CAL FOR,.A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> FIGNED ; TITLE: DATE: <br /> (DRAW PLOT PLKN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />'HASE I . . <br />,PPL ICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE LIL FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION ^ ' DATE pp <br /> H 142F;- —0011- 17_77 q 1 1'70 nxt <br /> 1 <br />