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SAN JOAQUIN LOCAL HEALTH DISTRICT •' <br /> 4 . FiICE 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 1 Year From Date Issued <br /> Complete In Triplicate .� <br /> Application is hereby made to the San Joaquin Local Health District fora permit: to construct <br /> and/or install the work herein described. This application, is .made incompliance with San <br /> ,'oaquin County ordinance No. 1862 .and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS_ •ZEST �l ��,I CITY/TOWN <br /> Owner' s Name 40.1 C. Phone �,l <br /> Address_c ,7 City IS-2 <br /> Contractor's NameL oat <br /> License#yZ3&� Phone J �J j2_ 7t/6 <br /> F <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"! IilSUR mrr ON FILE WITH SJLHD? YES NO a <br /> TYPE OF WORK (Check) : NEW WELL EM DEEPEN 0 f - RECONDITION ❑ DESTRUC iON <br /> WELL-CHLORMATION ❑ .-.WELL ABANDONMENT p "OTH-ER ❑•-- <br /> PUMP INSTALLATION. ❑ ., PUMP= REPAIR 0 PUMP REPLACEMENT ❑ <br /> DISTANCE ATO NE.ARE-ST:—SEPTI&.TANf� SEWER LINES ,//a '.� PIT PRIVY <br /> „w.. , SEWAGE DISPOSA FIELD / CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINgb4PRIVATE DOMESTIC WELL =-_-PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _ f <br /> - i <br /> Domestic/private Drilled Dia. of Well CasingY <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> Cathodic Protection <— Ro'tary ' ''�,:' Type of Grout CEA•c4.w <br /> Disposal Other Other Information <br /> Geophysical 4 Surface Seal Installed b <br /> PUMP INSTALLATION: ;Contractor <br /> Type- of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br />`DESTRUCTI-6N, <br /> "DF WELL: Well Diameter Approximate Depth'. <br /> Descri"be Materia an- - 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 AGROUT SP CT RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DRAW PLOT PL N ON REVERS& SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Y <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> 'PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE --;Z <br /> � J <br /> CLI 1nOc u <br />