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SAN JOAQUIN,LOCAL HEALTH DISTRICT <br /> OFFICE USE: <br /> 1601 E. Hazelton Ave. >, Stockton, CA 95205 Permit No.7 <br /> Telephone:. {209} 466•-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> i <br /> Thi s . Permit, Ex ires 1 Year From Date .Iss,ued <br /> .Complete In .Tri plicate , <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. compl-iance with San <br />,oac7Jin County erdinan/ce No[. 1862 and the :Rules and Regulations of the San Joaqu <br /> District. in Local :Health <br /> l� .� <br /> EXACT STREET ADDRtrSS C-ITY/TOWN <br /> Owner' s Name Phone <br /> Address. . ���/ Li _ . City . . <br /> Contractor' s Nam cense Phone 3:; ;— <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION ItJSURA^ICE ON FILE WITH SJLHD? -YES NO <br /> TYPE OF WORK Check) : NEW WELL L DEEPEN' -� 'RECONDITION C3� DESTRUCTION-[,}- <br /> WELL CHLORINATION 0 WELL ABANDONMENT O OTHER( <br /> PUMP INSTALLATIONAPUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t <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 Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casin g <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 a <br /> F Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump H•P �- <br /> PUMP REPLACEMENT: State Work D& <br />' PUMP REPAIR: ❑State Work Done <br /> k - 'A rox~imate—De <br /> p th <br /> DESTRUCTION"OF'WELL: We11 DiamEter - PP p' W <br /> Descri be" Materi a and Procedure <br /> T 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 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-.EOR_,A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE TITLE: DATE: /o <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT CSE ONLY <br /> PHASE I' <br /> APPLICATION ACCEPTED_ -BY DATE = 7v <br /> 'ADDITIONAL COMMENTS: F <br /> PHASE II GROUT INSPECTION -PHASE III FIN INSPECTION <br /> JINSPECTION BY DATE -,- INSPECTION- <br /> _ INSPECTION BY A'EE <br /> 1178" 2Mi <br />