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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .11).1 fFICE USE: 1601 E. Hazelton Ave. , -Stockton, CA 95205 Permit No. <br /> 1� Telephone: (209) '466-6781 <br /> IC Date Issued _ , <br /> APPLICATION FOR WELL- CONSTRUCTION OR PUMP PERMIT <br /> 1 <br /> { (Complete In Trip,]i.cate)- <br /> Application is hereby made to the San Joaquin Local' Hea'lth District for a permit to construct 4� <br /> .and/or install the work-herein described. This application is' made- in compliance with San .,, <br /> Joaquin. County Ordinance No. 1.862 and the Rules and 'Regul ations of the San Joaquin Local Health i <br /> District. <br /> EXACT STREET ADDRESS /✓ ITY/TOWN <br /> �ac <br /> Owner's Name Phone <br /> Address City 2 <br /> ? frfli/..r1w� ��Dq r <br /> Contractor's Name Liceps Phone 0!V .?CJa <br /> IS CERTIFICATE OF WORKMAN'S COMPE'NSATION INSURANCE ON FILE WITH SJLHD? YES 0 <br /> TYPE OF WORK (Check) : NEW WELL C) DEEPEN RECONDITION DESTRUCTION( A t <br /> WELL CHLORINATION D WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TOINEAREST: SEPTIC TANK k_ SEWER LINES PIT PRIVY C^ 4 <br /> SEWAGE DISPOSAL -FIELD,,�o- ':t CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINGO{PRIVATE DOMESTIC. WELL%S: f_ PUBLIC DOMESTIC WELL ---, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. <br /> IndustrialCable Tool Dia. of Well Excavation -7 ' <br /> Domestic/private Drilled Dia. of Well Casin s, <br /> Domestic/public Driven Gauge of Casing � . <br /> Irrigation Gravel Pack Depth of Grout Seal qq - --� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information c <br /> Geophysical Surface Seal Insta ed b �-�..� <br /> PUMP INSTALLATION: Contractor <br /> 1 Type of Pump H, i <br /> PUMP REPLACEMENT: []State ..Work Done <br /> PUMP REPAIR! ❑State Work Done t. <br /> DESTRUCTIONIOF 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 5an-_Joaquin Local i <br /> Health_, Di sty.ct._. .Home owner or l fcensed agent" s s 1gnatuv^e certi fiesTthe" fol 1 owi ng': <br /> Isr j <br /> I certify that in the performance of the work for which this permit is issued, I shall <br /> not em l'1.o an <br /> P � Y y person in such manner as to become subject to Workman's Compensation <br /> laws ofica11fornia. <br /> I WILL CALLuFOR A G T NSRECTfON PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED wf <br /> TITLE: L,� -- DATE: <br /> P T ON REVERS I E s <br /> DEPA TMEN USE ONLY 3 <br /> PHASE I ---- <br /> APPLICATION (ACCEPTED BY DATEZ c <br /> ADDITIONAL COMMENTS: <br /> .PHASE If GROUT INSPECTION PHASE III ' INAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BYD TE 77 <br /> / 6 <br />_H 14 26 Rev 9/7R <br />