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A. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR- OHICE 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 i 6 -7 <br /> This Permit Ex ires 1 Year From Date Issued <br /> Complete In Triplicate <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> nd/or ;nstall 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 CITY/TOWN <br /> wner's Name Phone ��_ <br /> ddress city &,Z,4424 <br /> ontractor's Name zz LicensePhone :�fy f--22/n_____ <br /> 5 CERTIFICATE OF WORKMAN'S CO!IPENSATIO'. IN1,'11 !CE ON FILE WITH SJLHD? YES NO <br /> YPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHL INATION ❑ WELL ABANDONMENT ❑ OTHER <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> iSTANCE TO NEAREST: SEPTIC TANK, SEWER LINESPIT PRIVY <br /> SEWAGE DISPOSAL FIELDS CESSPOOL/SEEPAGE TIT OTHER--- <br /> PROPERTY LINW4PRIVATE DOMESTIC WELL�..S2-t- PUBLIC DOMESTIC WELL ^ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - I Cab a Tool Dia. of We 1 Excavation /1 y <br /> Domestic/private Drilled Dia. of Well Casing 6 if <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection __Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> UMP REPLACEMENT: E]State Work Done <br /> UMP REPAIR: Q 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 accordar <br /> ith San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Loca <br /> ealth 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 CALI.,FORA GROUT IN CT N P I TO GROUTING AND A FINAL INSPECTION. <br /> I G N E D TITLE: DATE: <br /> DR PL VL-VN ON REVERS DE <br /> R DEPARTMENT,U5E NL <br /> iASE I <br /> )PLICATION ACCEPTED BY -2, At�s/�� Z16.'ADATE 8' /d ?�' <br /> )DITIONAL COMMENTS: r <br /> PHASE, GROUT INSPECTION p PHA5E I INAL INSPECTION <br /> ISPECTION BY ATE --'gyp INSPECTION DATE L <br />