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SAN JOAQUIN LOCAL HEALTH DISIR1L1 <br /> �TFF ICE U E: 1601 Hazelton Ave. , Stockton, CA ' 05 Permit No. -10? <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued-7-/Y-7r <br /> This Permit Ex fires 1 Year From Date Issued Crr <br /> ��1 Fo <br /> 1Ytc <br /> Complete In Triplicate (\(�'.'!�,/� JApplication is hereby made toi os <br /> and/orinstall the work herein described. This application is made in compliance with San <br /> ,oanuir County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. / <br /> EXACT STREET ADDRES��O <br /> �//j9CK(//L! ?�fD CITY/TOWN(]�F�� <br /> Owner's Name 11^4L Phone7S9-� <br /> Address f CityC�LB�». r1r <br /> Contractor' s Na s furl- cS"/ZC� License ' �2R Phone_'f <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO`! INSURANCE ON FILE WITH SJLHD? YES NO `— <br /> TYPE OF WORK (Check) : NEW WELL <br /> EEPEN RECONDITION C3DESTRUCTION El �J <br /> WELL CHL INATI WELL ABANDONMENT p OTHER I=1 <br /> PUMP INSTALLATI PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 Excavation <br /> &/6omestic/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 Se Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> a <br /> Describe Materiand Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc <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 alifornia." <br /> I WILL CAL OR A G 0 T VSPECTJO PRIO TO GROUTING AND NAL INSPECTION. <br /> SIGNED TITLE: DAT <br /> P OT PIAN ON REVERSE DE <br /> PHASE I FOR DPARTMENT USE ONLY <br /> 4PPLICATION ACCEPTED BY DATE ZZI 7�' <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' ' y <br /> -W 1A')r D- 10 77- 1 170 I)m <br />