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SAN JOAQUIN LOCAL HEALTH DISTRICT Permit No. <br /> n Ave. ,: Stockton, CA 95205 �--�`� <br /> OFFICE USE: 1601 E. Hazelton 466-6781 <br /> FQR Telephone: (209) Date Issued a3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit .Ex fres l Year From Date Issued ; <br /> Complete In Tri pl i cafeto <br /> hereby made to the San Joaquin Local Health District forca cormit <br /> mpliance; with nSan <br /> construct <br /> Application is h Y <br /> and/or install the work hereindescribed. This application is ma <br /> , ,n Count Ordinance ��o. 1862 and the-Rules and -Regulations of-the .San Joaquin Local .Healfh <br />,,oan.� Y <br /> District. 'l_;it700 C' - - CITY/TOW <br /> EXACT STREET ADDRESS r : ftk �c Phone <br /> ` <br /> Owner' s Name r City <br /> Address Phone <br /> License# <br /> iContractor' s Name i <br /> IS CERTIFICATE OF WORK41Afd'S COS�IPENSATIO"k I"1SURA"10E ON FILE 1r1ITH SJLHD? YES <br /> ITS <br /> OF WORK (Check) : NEW WELL Cif.. DEEPEN ❑ PRECONDITION Q DESTRUCTION C] <br /> WELL CHLORINATION L WELL ABANDONMENT 0 . OTHER C..1 <br /> PUMP INSTALLATION E31 PUMP REPAIR LY PUMP REPLACEMENT D <br /> PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC. TANK SEWER LINES {„ <br /> SEWAGE DISPOSAL FIELDTE DOMESTIGCrSS—PW���SEEPAGEPUBLIC—DO MESTICRWELL , G <br /> PROPERTY LINE PRIVA <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Ex11 cavation <br /> Drilled Dia. of Well ,Casing <br /> Domestic/private Driven - <br /> Domestic/public Gauge of Casing Depth of Grout Seal - <br /> 4,—Irrigation Gravel Pack <br /> Cathodic Protection - "Rotary �^ *� ,Type 'of Grout <br /> Disposal ` -OtherOther Information <br /> 1----7—Geophysical Surface SealIInstalled b <br /> PUMP INSTALLATION: Contractor <br /> Type -of Pump <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: p Sate Work Done 'Approximate Depth <br /> DESTRUCTION OF WELL: Wel 1IDiameter <br /> Describe Materia an Proce ure <br /> 1 <br /> in accrdan <br /> I hereby certify that I have prepared this applicationnd an andaRegulat�onsrk woflthe Sanbe eJoaquin_Loca <br /> iwith San Joaquin County Ordinances, State Laws , a <br /> Health District. Home owner or <br /> rltur <br /> othe gent' s sforawhichcthisfidpermiteisollowinissued�. I shall :,^ " ' <br /> "I certify that in the perform <br /> not employ any person in such manner. as to become subject to Workman s �Compensati�an <br /> laws of Californi-a." <br /> 11 WILL CALL FOR A.-GROUT- INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION• DATE: <br /> SIGNED ;L TITLE, <br /> DR W PL T PL N ON REVERSE SIDE <br /> ► FOR DEPARTMENT USE ONLY / <br /> PHASE I <br /> DATE f/z3 <br /> APPLICATION ACCEPTED BY -� <br /> � ADD.ITIONAL COMMENTS: P;HASE :I INAL NSPECTION - r <br /> PHASE II GROUT INSPECTION INSPECTION ATE `��?p <br /> INSPECTION BY DATE <br /> 8 22 <br />