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SAN JOAQUIN .LUGAL HEALIH U1SIKICI—EORQ -y <br /> FFICE USE/ 1601 E. Hazelton Ave:; Stockton, CA 95205 Permit No. <br /> Tel bone: (209) 466-6781 <br /> ssued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date I <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 Distri.ct .for a permit to construct <br /> and/or install the work herein described.,. This application is made in compliance with San <br /> loaQuin County Ordinance No. 1862 and the 'Rules and Regulations of the San Joaquin local Health <br /> District. <br /> EXACT STREET ADDRESS',2!5)L" a CITY/TOWN -- <br /> Owner' s Nameq,. Phone��2 -6'4_f . <br /> Address 11 r e�.Rr: <br /> Contractor's Name License# ° 010 Phone $ -- <br /> 1,.r e <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO", I"J URANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OFrWORK (Check) : NEW WELL DEEPEN ❑ RECONDITION Q DESTRUCTION❑ <br /> WELL CHLORINATION' o WELL ABANDONMENT ® OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANC`E `TO NEAREST: SEPTIC TANKD7 Q Y SEWER LJNES.#D4-t-- PIT PRIVY <br /> SEWAGE DISPOSAL .FIELD 101 f. CESSPOOL/SEEPAGE PIT __OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE' �. TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industr..ial F` Cable Tool Dia. of Well Excavation 'Z <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public r' 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:Dveau LeA <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump J.P. r <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and 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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 3 <br /> 4nf!!�:=DRW PLOT PLTN` ON REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE J <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> { <br /> 01 <br />