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"N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 %w Hazelton Ave. , Stockton, CA swe05 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 �O D <br /> application is hereby made to the San Joaquin Local Health District f�pe�l o Y- Slruct <br /> PP Y <br /> and/or install the work herein described. This application is made in compliance with San <br /> 'oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> )istrict. <br /> =XACT STREET ADDRESS 340 e S • W SCITY/TOWN T <br /> timer' s Name *►S SAO O J- Phone-40-39,3Z <br /> address P 0 . 1?d, (3-7 City <br /> :ontractor's Name Gc.A.RK. 1N . fE4UM, (4. 1AkLicense# 7G4o2 Phone Y 2— <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES IVO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> )ISTANCE TO NEAREST: SEPTIC TANK /60'-SEWER LINEJ4-/0J! PIT PRIVY <br /> SEWAGE DISPOSAL FIEL*Lo ! CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LI W60ORIVATE DOMESTIC WELL-1_ , PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavatio6 /0 x7eF <br /> Domestic/private Drilled Dia. of Well Casin 97 <br /> GDomestic/public Driven Gauge of Casing S <br /> Irrigation vel Pack Depth of Grout Sea]-rd iN0 Ot.A1u_i L G <br /> Cathodic ProtectionRotary Type of Grout 13 F /T 4#01 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal 7d b <br /> )UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> )UMP REPLACEMENT: ❑State Work Done <br /> )UMP REPAIR: ❑State Work Done <br /> )ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> [ 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 /> iealth 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 FOR GROUT I S EC ION PRIOR TO ROUTING AND A FINAL INSPECTION. <br /> IGNTITLE: DATE: G—i k '- 7 � <br /> DRAW PL L N ON REVERSE SIDE <br /> FOR EP RTMENT USE ONLY <br /> 'HASE I <br /> 1PPLICATION ACCEPTED BY DATE 5 <br /> 1DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY C�. . zC ac...OL DATE $ 7�U <br />