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c"u JOAQUiMIOCALHEALTH DISTRICT- <br /> FOR OFFICE USE: 1601 l Iazeltgn Ave. ; Stockton, CA J5 Permit No.29-//.S <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <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 a <br /> and/or install the-work herein described. This application is made in compliance with San <br /> Joanuin County Ordinance •k,o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. — <br /> EXACT STREET ADDRESS L4 <br /> \t� Y \. CITY/TOWN ' 2 <br /> Owner' s Name V \� Phone � <br /> Address City < <br /> Contractor's Name License)q')5 b Phone S— u <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES i/ NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN O RECONDITION [] DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT Q OTHER 0 � <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ 0C <br />(DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL MELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF' WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We Excavation <br /> omestic/private 1777 Drilled Dia. of Well Casing '- <br /> Domestic/publicDriven - Gauge of Casing L <br /> Irrigation - Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary ' Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br />'UMP INSTALLATION: Contractor hie , <br /> Type. of Pump I„ o H. <br />'UMP REPLACEMENT: Q State .Work Done .' ~ <br />)UMP REPAIR: ❑State Work Done r, <br />)ESTRUCTION OF WELL: Well. Diameter • r Approximate Depth <br /> Describe Material and ProceJ_vre <br /> • <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br />.rith San Joaquin County Ordinances, State Laws ,' and Rules and Regulations of the San Joaquin Local <br /> iealth District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that in theperformance 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.” 11, <br /> WILL CALL FOR A GROUT INSPECTION PRIOR: TO GROUTING AND A FINAL INSPECTION. <br />;IGNED TITLE: G '� Q� DATE: 7 <br /> (DRAW L L N ON REV RS IDE <br /> FOR DEPARTMENT USE ONLY <br />'RASE I / <br />,PPLICATION ACCEPTED BY DATE--.77 <br /> 0DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DAT Ej�arf-;9 <br />