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SAN JOAQUIN LOCAL HEALTH DISTPICT <br /> FOR FFICE USE: 1%0,1 E. Hazelton Ave. , Stockton, -,,,w 95205 Oermit N. .'7 `/- !i� <br /> Telephone. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued & -� 6 <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate-)- <br /> Application <br /> rip icateApplication is hereby made to the San Joaquin Local Health District for a permit to construct <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 /> District. oo�� <br /> EXACT STREET ADDRESS 2 (SSI / /pVCITY/TOWN <br /> Owner's Name AIF1-5oN R EAoU mix C( ,yCQi; T.6 Phone J-144 --.2 <br /> Address (:2 0,-E2 NogyV ,pP City AT6aK7-0A/ <br /> Contractor's Name {�yNNi�,I/-� � '©S. �!:��J�iNL� License g'/ Phone -rj�yr'— <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check).: NEW WELLEI DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENTr-1 OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0 PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: 0,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 .90 <br /> Domestic/private Drilled Dia. of Well Casing It <br /> Domestic/public Driven - Gauge of Casing _ <br /> Irrigation Gravel Pack Depth of Grout Seal �- <br /> Cathodic Protection Rotary Type of Grout C , n 1 En! 'r— <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: Z� <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 /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordan <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <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." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: by <br /> DR W PLOT PLAN ON REVERSE S DE <br /> FO EPARTMENT USE ONLY 01 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE y' <br /> A�; <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY (a, DATE CO <br />