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cfitZ .Z 5""' JOAQUIN LOCAL HEALTH •DISTRICTI <br /> FFICE USE: 1601 azeltor, Ave. , Stockton, CA ! 5 Permit No. 7 9 - q G A <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CT <br /> CONSTRUION OR PUMP PERMIT Date Issued -iG - 7y <br /> This Permit Expires 1 Year From Date Issued °t <br /> (Complete In Trip ica e <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 />'oanuin County Ordinance No. 1862, and the Rules and Regulations of the San Joaquin Local Health <br />)istrict. <br />=XACT STREET ADDRESS��� �}� � // �, CITY/TOWN <br />)wner's Name—a. PhoneS— <br />' ddress :*r City <br />:ontractor' s Nam License#.ip9b /.P Phone--4--2.9- <br /> TS <br /> honef'.2.9-IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> STYPE OF WORK (Check) : NEW WELL04 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT O OTHER <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br />)ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE D MESTIC WELL - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE. OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ' <br />� estic/private Drilled 'Dia. of Well Casing / A <br /> Domestic/public '—Driven - Gauge of Casing l - <br /> Irrigation ', Gravel Pack Depth of Grout Sea I <br /> ' <br /> Cathodic Protection v4t6tary Type of Grout <br /> Disposal ; Other Other Information <br /> Geophysical Surface Seal Insta ed b <br />-)UMP INSTALLATION: Contractor <br /> Type of Pump H. <br />)UMP REPLACEMENT: ❑State Work Done <br /> d)UMP REPAIR: ❑State Work Done <br />)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material apd Procea'ure <br /> Q hereby certify that .I have prepared this, application and that the work will be done in accordanc <br /> Frith 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 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 Wprkman's Compensation <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />;IGNED TITLE: . DATE: <br /> � <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR ' EP RTMENT USE ONLY <br />"HASE I. �� <br />{PPLDATE <br /> ICATION,ACCEP`TED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE .r-- :;Z INSPECTION BY C DAT a.6 <br /> . . .-- o c,Wi�0 Ire <br />