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� . SAN JOAQUIN "LOCAL HEALTH DISTRICT - _ �W <br /> FFICE USE': 1601 E. Hazelton .Ave. , Stockton, CA 95205 Permit Nom <br /> �. „ ..- p one: (209),466w678I <br /> Telephone: Date Issued <br /> ;+r. .. b _ <br /> APPLICATION. FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires' 1 Year From Date Issued <br /> i Complete In Triplicate ' <br />�A' 1 'cation is hereby made to the San Joaquin local Health District fora permit to construct <br /> d%or install the work herein described. This application is made in compliance with San <br /> Joanuin County Ord$gance No. . 1862 dndathe Rules and Regulations of the San Joaquin Lacal Health <br /> Distr ct. '� 4 <br /> W <br /> EXACT STREET' ADDRESS ` / 4/ CITY/TOWN <br /> ¢ r <br /> Owner's Name PhonefO' _ <br /> Address 3 / _ City <br />".Contractor's Name License fS Phone ! � t <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"J INSURANCE ON FILE WITH SJLH D? YES- NO <br /> TYPE OF WORK (Check) -" NEW WELLC]�— DEEPEN ❑ y RECONDITION ❑ DESTRUCTION❑ <br /> WELL. CHLORINATION ❑ WELL ABANDONMENT E] OTHER❑ <br /> PUMP INSTALLATION 0 PUMP •REPAIR❑ PUMP REPLACEMENT C] � <br /> DISTANCE. TO NEAREST: S£PTIC`TANK , , gip` SEWER LINES MY PRIVY I�I <br /> 'SEWAGE DISPOSAL FIELD/,n2 CESSPOOLISEEPAGE PIT ' OTHER f <br /> � <br /> .'" PROPERTY LIN . �JPRIVATE DOMESTIC WELL ; PUBLIC DOMESTIC WELL <br /> t INTENDED USE TYPE OF WELL CONSTRUCTEION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well EX tion <br /> *ie'stic/private ° Drilled Dia. of Well Casing <br /> - Domestic/public Driven Gauge of Casing 4 <br /> Irrigation . Gravel Pack Depth of Grout Seal Q <br /> Cathodic Protection ..Rotary Type of. Grout <br /> Disposal Other Other Information <br /> - Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: -Contractor ' <br /> Type lof Pump H.P. 11 - <br /> PUMP- REPLACEMENT: []State Work Done <br /> PUMP REPAIR: QState Work Done <br />#.DESTRUCTION OF WELL: -Well Diameter - Approximate, Depth <br /> Describe Material and Procedure <br /> I...:hereby. certify that .I-'have prepared thi;s4 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 --lice ed agent's signature certifies the following: <br /> "I certify that in the performanck; Vf the work for which this permit is -issued, I shall . <br /> not employ Any person in such manner as to Fecome subject to Workman 's Compensation <br /> laws of California:" <br /> I WILL CALL FOR A1G•ROUT INSPECTION P IOR TO' GROUTING AND A FINAL INSPECTION. <br /> " IGNED TITLE: DATE: <br /> (DRAW PLOT PLN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 'PHASE I . Q <br /> APPLICATION ACCEPTED BY DATE <br /> `ADDITIONAL COMMENTS: ` <br /> PHASE II GROUT INSPECTION. PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY C• � . _ DATE r y� <br /> PH,I d?K Pow 19-77 2M�, <br />