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SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> - FORFFICE 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 F1•/_1 -g <br /> This Permit Expires .1 Year From -Date Issued <br /> Comp ete n Triplicate <br /> Application is hereby made to ;the San Joaquin Local Health District for a permit:to construct <br /> and/or install the work her'ein' desct^ibed. - This applicationiis made in compliance with San <br /> Joaquin County Ordinance No: 1:862 and the- Rules and-Regulations of the San. Joaquin' Local Health <br /> District. <br /> rea r <br /> EXACT STREET ADDRESS � � ,, Y`1 8� �ac�` � A�lave a�v',1'3�TY/TOW-N <br /> Owner's Name Phone o <br /> City <br /> Address. -Q <br /> Contractor's Name , ,, License4� Phone``1 X <br /> IS CERTIFICATE OF WORKMAN'S C6MPENSATIO'1 INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WOW (Check) :. - NEW WELL O DEEPEN E7 RECONDITION; DESTRUCTION[] <br /> WELL CHLORINATION p WELL-ABANDONMENT 0 OTHER( <br /> PUMP INSTALLATION Q PUMP REPAIR E3 PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES—" PIT' PRIVY <br /> SEWAGE, DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE 06 ESTIC WELL - PUBLIC DIMESTIC WELL fl� <br /> INTENDED USE -TO E .OF WELL CONSTRUCTION SPECIFICATIONS o <br /> IndustrialCable Tool Dia. of WellExcavation <br /> Domestic/private Drilled Dia. of Well Casing �h <br /> Domestic/public Driven Gauge of Casing I-rrigation 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 /> •.PUMP INSTALLATION: Contractor <br /> �- Type df 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 1 ,havelprepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home ownerlor 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 C L F R A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> RAW PLOT PLVN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE ell l2k, <br /> APPLICATION ACCEPTED BY ; <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE III FINAL IN T <br /> ,.INSPECTION Y DATE INSPECTION BY „ - 4Z D <br /> �„�, 7 2 <br /> r r�� �\(__ 1%8 M <br />