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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 2�?--j_y4/i <br /> Telephone: (209) 466-6781 <br /> 24 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 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 install the work herein described. This application is made in compliance with San <br /> oanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> istrict. <br /> XACT STREET ADDRESS ,6 a 4Ly /✓ Ids/f --ye CITY/TOWN <br /> wner' s Name 14—o Phone <br /> ddress �� �e e1� Ci ty S,74 G <br /> ontractor's Name License# -;�1s--Phone z <br /> S CERTIFICATE OF WORKMAN'S COPIPEN In4m INSURANCE ON FILE WITH SJLHD? YES „� NO <br /> YPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 � <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [7N c <br /> ISTANCE 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 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> UMP INSTALLATION: Contractor S;L / ,- " <br /> Type of Pumplow H.H.P. S <br /> UMP REPLACEMENT: X State Work Done 'i4,4t- .��,r «, a e„., <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 accordani <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 CALL FOR A GROUT INSPECTIO I R ROUTING AND A FINAL INSPECTION. <br /> IGNED �� -Aulkbx��: DATE:. <br /> (RRAW PL L N 0 REVERSE SIDE <br /> FOR DEP RTMEN USE ONLY <br /> 1ASE?PLI I <br /> PLICATION ACCEPTED BY ,,,., DATE <br /> DDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHA II FINAL INSPECTION <br /> VSPECTION BY DATE INSPECTION BY DA—TE---q-- <br /> J <br /> ATE -J 1 A )C n— 1 1) -7" 1 1-7 0 11 Ld <br />