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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />—FOR:--OFFICE USE• 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.—Z ?moo <br /> Telephoner (209) 466-6781 <br /> Date Issued -5 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> '�7 <br /> This Permit Ex ires I 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 /> Joaquin' County Ordinance No. 1862. and the Rules and Regulations of the San Joaquin Local Health a <br /> District. i <br /> EXACT STREET ADDRESS D, Ag-RsCITY/TOWN <br /> Owner's Name _77' <br /> ,e Phone /— Z.1709ll <br /> Address <br /> City <br /> Contractor' s Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMIPENSATIO'N IINSURAMlCE ON FILE WITH SJLHD? YES NO <br /> _ G <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION Q DESTRUCTION S W � <br /> WELL CHLORINATION CJ WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT,�PRIVY -, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tbol Dia. of Well -Excavation- ­ - <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. Za <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: QState Work Done 11' 40 JAZ • <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure �' - <br /> I hereby certify that I have prepared this application and that the work will be done in. accordancE <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 shah <br /> not employ any person .in such manner as to become subject to Workman's Compensation . <br /> laws of California." <br /> II I WILL CALL FOR A G T INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> (DRAW <br /> PL T PUN ON REVERSE SIDE <br /> FOR DEP RTM IVT USE ONLY <br /> PHASE I DATE Z <br /> APDLICATI'ON ACCEPTED BY ` 70 <br /> ADDITIONAL COMMENTS : J ' <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION ,BY . F.,' DATE INSPECTION BY l'. /�, _ _ DATE <br /> _fZ) <br /> .. .. <br /> i /-751 7 M <br />