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oY&11SSD1"JOAQUIN LOCAL HEALTH DISTRICT 1010S <br /> FOR OFFICE USE: 1601 E azeltWL, ye. , Stockton, CA 9 5 Permit No.*7 ,9 e� <br /> Telephone: (209) 466-6781 <br /> APPLI.CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issue4, -a.7 4 <br /> This Permit Expires I Year From Date Issued v' <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 />'oanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health - <br /> Distr4ct. <br /> ZXACT STREET ADDRESS .�9f7 i�i�Gio _ �J�Ai� e� CITY/TOWN `1 <br />)wner's Name—.9, <br /> �4 Phone — <br /> Address ,5� / — City <br />:ontractor's Name License__#.&5 g6 Phone JS _ e0— <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br />'TYPE OF WORK (Check) : NEW WELL R] DEEPEN ❑ •RECONDITION ❑ DESTRUCTION❑ (Tr <br /> WELL CHLDRINATION ❑ WELL ABANDONMENT ❑ OTHER'O 7E <br /> PUMP INSTALLATION ❑ PUMP. REPAIR❑ PUMP REPLACEMENT ❑ <br />)ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY, 61 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER IT11 <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELD <br /> INTENDED USE : TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation I / _ <br /> mestic/private Drilled Dia. of Well- Casing/z�4f—' <br /> Domestic/public Driven - Gauge of Casing .1_,Cyj . <br /> Irrigation r 'Gravel Pack Depth of Grout Seal �D <br /> Cathodic Protection '7—e_ tSry Type of Grout <br /> Disposal Other Other Information !/&;, <br /> Geophysical Surface Seal Installed by: <br />'UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />'UMP REPLACEMENT: []State Work- Done <br />,)UMP REPAIR: ❑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 /> gith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> dealth 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 /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING SAND A FINAL INSPECTION. <br /> IGNEDTITLE; DATE: <br /> ff W• PL T L N ON REVERSE DE <br /> FOR DEPARTMENT USEONLY ` <br />'HASE I < <br />.PPLICATION ACCEPTED BY PATE1f-- Z=Z/r <br />.DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION B 6 DATE ��� INSPECTION BY ATE / Z <br />