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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , .Stockton, CA 95205 Permit No. <br /> Telephone: ' (209) .x'66=6781 <br /> APPLICATION FOR WELL CONSTRU . ION OR PUMP PERMIT Date Issued -5 "y 7 <br /> This Permit Expires 1 Yea a 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/oar install the work herein described. This .appl,ication is made in compliance with. San <br /> Joaquin County Ordinance No.. 1862 and the Rules . andfRegulations of the San Joaquin Local Health <br /> District. [ <br /> EXACT STREET ADDRESS CITY/TOWN <br /> owner's Name Phone <br /> Address City G <br /> Contractor's Name License# G-- !Q Phone <br /> IS CERTIFICATE OF WORKMAN'S C014PENSATIOIN INSURANCE ON FILE WITH SJLHD? E - NO <br /> I <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN CI RECONDITION ❑ DESTRUCT ION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION EN PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK_L&02SEWER LINES e® 1 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN PRIVATE DOMESTIC WELL PUBL c DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing - <br /> Domestic/public —Dr iven 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 J G <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <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 shall <br /> not employ any person in such manner as to become subject to Workman's Compensation { <br /> laws of California. " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE: DATE: •�� �"__ <br /> 4 (DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE- ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Cf— <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4 DATE / - f <br /> _.. EH 1426 Rev:-12.-77 <br />