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N JOAQUIN LOCAL HEALTH U1SfK1l <br /> FQRFFICE USE: i Oi_ Hazel ton ,Ave. , Stockton, CA { X205 Permit No. g=/sd� <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 /> oplication is hereby made to the San Joaquin Local Heal th''District for a permit to construct <br /> -W or install the work herein described. This application is made in compliance with San <br /> )an.:in County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> 15t►"'CL. <br /> r�,8 � :� <br /> 4ACT STREET ADDRESS � ._ In CITY/TOWN <br /> ' rner's Name r k ft)-& e s Phone <br /> € idress S . c /C,,,,,, le�z Ci ty mmke — <br /> )ntractor's Nfame f ,- License# Phone <br /> S CERTIFICATE OF WO MM; S CO"SPEtJSATIQ"! IiJSURA^fCE di1 FILE WITH SJLHD? YES fJ0 <br /> !PE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ �DESTRUCTI.ON -` <br /> WELL CHLORINATION [] WELL ABANDONMENT ❑ OTHERS <br /> PUMPmlNSTAL-L-AT.IOPUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> , <br /> [STANCE 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 /> -, Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ��Gravel Pack Depth of Grout Seal W `4 <br /> Cathodic Protection Rotary Type of Grout r <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> IMP INSTALLATION: contractor IL <br /> Yfype of Pump--L- P. <br /> UMP REPLACEMENT: ❑ State Work Done u <br /> JMP REPAIR: ❑State Work Done <br /> :STRUCTION OF WELL: Well Diameter Approate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordan( <br /> ith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <br /> =alth 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 /> WILL CALL OR GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. n <br /> G N E DX TITLE: DATE:� d� / dC <br /> (DRAW PLOT PLANT ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY �y414--e <br /> LASE I <br /> 'PLICATION ACCEPTED BY DATEDop <br /> )DITIONAL COMMENTS : - <br /> PHASE II GROUT INSPECTTON PHASE III FINAL INSPECTION <br /> SPECTION BY DATE INSPECTION BY DATE <br />