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E• 'i <br /> I.. <br /> E; <br /> :i <br /> JU <br /> ✓ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> :-_ <br /> Telephone: (209) 466-67811 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Dat.. Issued/ _JJ,.�g' <br /> This Permit Expires 1 Year From Date Issued <br /> (Complete In rip icate <br /> Application is hereby made to the San Joaquin Local Health District for a pear to construct J <br /> and/or install the work herein described. This application is made in compliance with San 111 <br /> � .'oaQuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health ` <br /> CEistrict. E� i:. <br /> ' EXACT STREET ADDRESS _ I CITY/TOWN <br /> Owner's <br /> Name Phone <br /> Address <br /> C i ty <br /> Contractor's Name G License# &1?/,-3 Phone <br /> 77 <br /> IS CERTIFICATE OF Wnft"TAN S COMPENSATION INSURAINCE ON FILE WITH SJLHD? YES X I40 ' <br /> TYPE OF WORK (Check): NEW WELL IN DEEPEN ❑ RECONDITION Q DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT p OTHER <br /> a <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ it PUMP REPLACEMENT ❑ � <br /> DISTANCE TO NEAREST: SEPTIC TANK /00* SEWER LINES PIT PRIVY :+ <br /> SEWAGE DISPOSAL FIELD roe" CESSP OL/SEEPAGE PIT " OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLTE—bESTIC WE T <br /> INTENDED USE TYPE OF WELL :CONSTRUCTION SPECIFICATIONS € <br /> n ustr a aFle"`�T o Dia, of Will Excavation <br /> omestic/private Drilled Dia. of Well Casing. <br /> D Domestic/public ` --Driven - Gauge of:Casing <br /> Irrigation =Gravel Pack Depth of;;Grout ea I <br /> Cathodic Protection _Rotary Type of Grout <br /> isposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMVINSTALLATION: Contractor r <br /> : Typo of Pump .I <br /> ' PUMP' REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: pState Work Done <br /> DESTRUCTION OF WELL: Well Diameter `; _ Approximate Depth <br /> Uescribe MaterTT and Proce vre <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." if <br /> 1 WILL CALL FOR A GROUT JJYSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TLE: DATE: <br /> JAW PLOT PLANOPR REVERSE SIDE) <br /> FOR DEPARTRNT USE <br /> PHASE I j <br /> ., L�"ION ACCEPTED BY •L. DATE <br /> ADDITIONAL COMMENTS: <br /> PH SE 11 GROWT INSP€'CION 11PHASE III FIML INSPECTION <br /> INSPECTION BY DATE INSPECT16 BY DATE <br /> ps— <br /> I, <br /> r[� H <br /> EH 1426 Rev. 12-77 x'1'8 2M <br /> 1� <br />