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SAN JOAQUIN LOCAL HEALTH DISTRICT 5 Permit No. 9 -SC_� <br /> FOR FFICE USE:T 1601 E. Hazelton Ave. , Stockton, CA 9520 <br /> Telephone: (209) 466-67$1 pate Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ices 1 Year From Date Issued <br /> i� Complete In Triplicate <br /> Application is hereby made to the San Joaquin Locail Health District fora permit o co structs <br /> and/or install the work herein.idescribed. Ties ais application <br /> plica i on i nsmofethe Sariin pJoaquenwLocalith aHealthdrr <br />'oaquin County Ordinance .,o. 1862 and the Ru g „� <br /> District. <br /> CITY/TOWN � <br /> Phone <br /> EXACT STREET ADDRESS� O, 3 -7 2-0_ ��i <br /> Owner' s Name { <br /> City <br /> Address <br /> � License# Phone <br /> Contractor's Name µ <br /> I5 CERTIFICATE OF WORKMAN'S COIPENS'ATIO"J -INSURANCE ON FIL£ WITH SJLHO? YES NO <br /> TYPE OF WORK (Check) : NEW WE1L❑, DEEPEN [:] -,4 RECONDITION Q DEOTHERTI�N <br /> WELL CHLORINATION WELL ABANDONMENT ❑ p <br /> PUMP�INSTALLAT,ION: PUMP REPAIR❑ PUMP REPLACEMENT 0 o� <br /> DISTANCE TO NEAREST: SEPTIC TANK FIELD <br /> LINES <br /> CESSPOOL/SEEPAGEY IT OTHER , <br /> SEWAGEDISPOSAL- BLIC DOMESTIC WELL <br /> f PROPERTY LINE -. PRIVATE DOME5TIC WELL �---- PU <br /> INTENDED USE TYPEOT F WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable To Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection <br /> Rotary `x d; Type of Grout <br /> Disposal OtherF _ Other Information <br /> Geophysical Surface Seal Instal ed b : <br /> IPUMP INSTALLATION: Contractor H . <br /> Type of Pump io m b <br /> JPUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State-,Wor ND6ne s ;{ <br /> f7 <br /> E' Approximate Depth D <br /> DESTRUCTION OF WELL: Well Diameter s <br /> Describe Mat ria an Proce r <br /> E <br /> { I hereby certify that I have prepared this appTication and that the work will be done in accordant <br /> Ewith San Joaquin County Ordinances , State+Laws , and Rules and Regulations of the San Joaquin Local <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 Compensati.on <br /> laws of California." ' <br /> I WILL CA F A GROUT FECT ON PRIOR TO GR�OUTI�NG-AND A FINAL INSPECTION. / 7 <br /> 'SIGNED TITLE: DATE: <br /> f G <br /> i DR W PLOT PL N ON REVERSE SIDE <br /> F FOR pEpARFTMENF USE ONLY <br /> PHASE I - :BBY] <br /> -,.� �. DATE <br /> - <br /> IAPPLICATION ACCEPTED �" <br /> .ADDITIONAL COMMENTS : PHASE III FINAL INSPECTION <br /> PHASE II OUT O <br /> :sINSPE N j { <br /> ,INSPECTION BY DATE INSPECTION B DATE <br />