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SAN JOAQUIN' LOCAL HEALTH DISTRICT ' <br /> FOR FFICE USE: 1601 l iazelton Ave. , Stockton, CA J5 Permit No. 9_?o <br /> ` Telephone: . (20g) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued G- 7-� <br /> This Permit Ex ires 1 Year "From Date Issued <br /> (Complete in triplicateT <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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health 4- <br /> District. t`-3a< <br /> EXACT STREET ADDRESS ,,Z3 ( �� �1��� CITY/TOWN <br /> Owner's Name / . �-7 c�` Phone��3s"- <br /> Address City <br /> Contractor' s Name License#2.38r,01 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES JC NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ ' RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION [ PUMP REPAIR O PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD. CESSFPOL/SEEPAGE PIT OTHER I� <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL G <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. ,of 'Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation IGravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface-Seal Installed by: e <br /> PUMP INSTALLATION: Contractor- " ' f <br /> Type of 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 I have prepargd 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 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 Compensation <br /> laws of California.. . <br /> I WILL CALL FOR T INS TION PRIOR TO GROUTING' AND A FINAL INSPECTION. <br /> SIGNED _ TITLE: DATE: <br /> PL ON REVERSE SIDE <br /> F R DEPARTUSE ONLY <br /> PHASE I <br /> PPLIC TION ACCEPTED BY DATE ' ZS� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION � <br /> INSPECTION BY DATE INSPECTION BY (_esi DCATE1g <br /> U7—�`y` <br /> 1 V79 ort <br />