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SAN JOAQUIN LOCAL HEALTH DISTRICT permit No. � "7 <br /> 1601 E. Hazelton Ave. , Stockton, CA 95205 Y <br /> OFFICE USE: 4fi6-6781 <br /> ;� Telephone: (20 ) Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Thi" Permit Ex ires, 1 Year From Date Issued <br /> Complete In Triplicate <br /> 1� <br /> made to �'the San Joaquin Laca1 Health District for a ptwithnSanuct. <br /> Application is hereby plication is made in compliance <br /> and/or install the work herein" described. This ap <br /> Joaquin Count d Regulations of the San Joaquin Local health <br /> Y Ordinance No. 1862 and the Rules -an <br /> District. CITY/TOWN c <br /> EXACT STREET ADDRESS <br /> phone <br /> Owner's Name City .c <br /> Address � J.� Phone <br /> �-� Li cense# 7�Q0 <br /> Contractor' s Name / NO <br /> TS CERTIFICATE OF wnRKMAWS CO""PENSATIO�! I�lSLRA <br /> INCE ON FILE VIITH SJLHD? <br /> YES ------- -- <br /> DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ b` <br /> TYPE OF WORK (Check) : NEW WELL WELL ABANDONMENT ❑ OTHER n <br /> WELL CHLOR <br /> INATION [J <br /> PUMP INSTALLATION Cl PUMP REPAIR❑ PUMP REPLACEMENTV <br /> PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT <br /> PIT_ OTHER <br /> SEWAGE DISPOSAL FIELD <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL------ PUBLIC ECIFICATIONS <br /> TYPE OF WELL <br /> CONSTRUCTION . — <br /> INTENDED USE Cable Tool Dia. of Well Excavation <br /> Industrial Drilled Dia. of Well Casing- <br /> =Domestic/pr' ivate <br /> asing`Domestic/private Driven Gauge of Casing <br /> Domestic/public 1 Gravel Pack Depth of Grout Seal <br /> Irrigation i Rotary Type of Grout <br /> Cathodic Protection Other___,_ _ Other Information <br /> Disposal Surface Seal Installed b <br /> Geophysical <br /> [ PUMP INSTALLATION: Contractor H.P. <br /> Type'"I1 of Pump <br /> f A< <br /> f �".� � � •' hires _ , <br /> PUMP REPLACEMENT: AState Work Done <br /> PUMP REPAIR: (State Work Done Approximate Depth <br /> DESTRUCTION OF WELL: Welilk ameter <br /> Describe Materia an Proce ure <br /> I hereby certify that I have prepared this applicatioRuleSand <br /> andthat <br /> Regulationswill <br /> the Sandone <br /> JoaquinoLoca <br /> with San Joaquin county Ordinances , State Laws, and <br /> Health District. Home owner or lancesed of then works forature whichcthisfpermiteisoissued, i shall <br /> "I certify that in the performa <br /> as to become subject to Workman' s Compensation <br /> not employ any person in such manner <br /> laws of California. <br /> 4I WILL CALL FOR A GROUT INSP TI4 RIOR TO GROUTING AND A FINAL INSPECTI0�1• DATE: �r�- <br /> TITLE: <br /> SIGNED T PL N ON REVERSE <br /> DR �! PL SIDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I DATE r ` <br /> : APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III F NAL INSPECTION <br /> PHASE II GROUT INS ECTION INSPECTION BY • <br /> INSPECTION BY DATE <br />