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SAN JOAQUIN- LOCAL HEAL-fH DISTU Cf �., a <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No._7,��).kfwl. ' <br /> Telephone: (209) 466-6781 j <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> - - <br /> This Permit Expires 1 Year From Date Issued .: <br /> Complete In Triplicate , <br /> Application is hereby made to` the. San Joaquin Local Health District for a permit tb'� construct <br /> and/or install the.;work hereinideserib'ed. This application is made in compliance with San <br /> uoan�j 7 n County. Ord:i nance J,'o. 1862"�a'nd.I the Rules and Regulations of the San Joaquin Local Health <br /> i s t r :c 176l t.. r '`.,4-r� +e X77,CO t 177- <br /> EXACT STREET ADDRESS C D+ i E CITY/TOWN reel � i <br /> • Z —� �4/ y <br /> Owner's Phone Name C l <br /> Address City G <br /> Contractor' s Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES Ido <br /> TYPE OF WORK (Check) : NEW WELL C] DEEPEN ❑ RECONDITION Q DESTRUCTION - ¢WELL CHLORINATION 0 WELL, ABANDONMENT 0 OTHER 0 �. � <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT a tz-W13 <br /> DISTANCE TO NEAREST: SEPTIG `TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL 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 Excavation _ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel 'Pack Depth of Grout ^ <br /> Seal0 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor Se <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUC-TION-OF WELL: - Well Diameter �. _ ... _ _ A proximate-Depth- -' - . <br /> Describe Mate'rial aH 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 INS EC N PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> D AW PLOT PLTN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY Trra ,7g ' <br />; PHASE i rte <br />, APPLICATION ACCEPTED BY 1 DATE l Z - <br />. ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT-ION PHASE 1,I1 FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY W DATE // 9 7� <br /> 1_J 7 8 2M�, <br />