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o`�icL`�,'SAN JOAQUIN LOCAL HEALTH DISTRICT `c <br /> FOR OFFICE USE: 1601 l iazelton Ave. Stockton, CA 05 Permit No. 7 9 - y G D <br /> ' Telephone72;b9) 466-6181 , <br /> --� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 6-10-7 <br /> This Permit Expires 1 Year:From Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> Joanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Distr4ct. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name Phone <br /> AddressJ-:�t `L!� // ��, City <br /> Contractor's Nam . .,,, _ 2s,. �, <br /> 00:. / , License#gogi P/? Phone s,?.Z- /D3i Cfl <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION.❑ DESTRUCTION❑ <br /> WELL CHLORINATION p WELL ABANDONMENT p OTHER 0 (T <br /> PUMP INSTALLATION ❑ PUMP REPAIR O PUMP REPLACEMENT [1 7% <br />'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE- PIT OTHER C. <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL G <br /> INTENDED USE TYPE OF WELL 'CONSTRUCTION SPECIFICATIONS <br /> InOustrialCale Tool Dia. of Well Excavation <br /> vVoomestic/private Drilled Dia. of Well Casing s <br /> Domestic/public Driven - Gauge of Casing /' � _ <br /> Irrigation Gravel Pack Depth of Grout Seal SO <br /> Cathodic Protection wry Type of Grout <br /> Disposal Other Other Information /,}J <br /> Geophysical +' Surface Seal Ins ta ed by: <br />?UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />)UMP REPLACEMENT: []State Work Done <br />'UMP REPAIR: O State Work Done <br />)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure` <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br /> lith San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <br /> lealth District. Home owner or licensed agent' s signature certifies the following: <br /> "I certify that in the performance of the vork 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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> I G N E D TITLE: DATE: <br /> . . (DRAW PLOTT15MN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> HASE I <br /> PPLICATION ACCEPTED BY DATE yr 7179 <br />.DDITIONAL COMMENTS: lab <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> NSPECTION BY1 ° DATE = INSPECTION BY _ ATE ?-12 1 <br /> ,..1 04� _ <br />