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SAN JOAQUIN LOCAL HEALTH DISTRICT �`�• <br /> FnRFFICE USE: 1601 E. Hazelton Ave. , .Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-67.81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/i-�r�g- <br /> This ,Permit Expires 1 (Year. From Date Issued <br /> 4 <br /> (Complete In, Triplicate) <br /> , Application is hereby made to the San Joaquin Local Health'-District fora permit to construct <br /> ., and/or install . the work! herei-n described. This application is made in compliance''with' San <br /> N �oaquin County Ordinance No 3 62 and t e Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> 'EXACT STREET ADDRESSIlt" CITY/TOWN' <br /> Owner' s Name Phone <br /> Address <br /> City, <br /> Contractor.'s Name' License# Phone <br /> IS CERTIFICATE OF 'WORKMAN'S COMPENSATIO1111 Ift4S A"cCE ON FILE WITH SJLHD? YES NO <br /> . TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION [IDESTRUCTION❑ <br /> WELL CHL RINATION ❑ WELL ABANDONMENT p OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ �_ <br /> DISTANCE TO NEAREST: SEPTIC TANK &pL SEWER LINES PIT PRIVY oc <br /> SEWAGE DISPOSAL FIELD //o/4- 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 /> _X—Domestic/private _Drilled Dia._ of.We11_Cas7_n.g., <br /> Domestic/public ; Driwen � ti Gauge of Casing- <br /> Irrigation �-- � -°Graved •Pack -------Depth of ,Grout Seal- - <br /> I.—Cathodic Protection Rotary_ T s Type of..�6.rout___ _ _ <br /> Disposal Other Other Information �. <br /> Geophysical <br /> Surface Seal Installed b : <br /> PUMP INSTALLATION: Con.trac-tor J ' <br /> Type ;ofpPump H. .� <br /> PUMP REPLACEMENT: F]State.Work Done <br />� PUMP .REPAIR: ❑State Work Done { <br /> DESTRUCTION OF WEAL: Well Diameterr s . � ..:._ <br /> Approximate Dept- <br /> hM <br /> Describe�Materia 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 shall <br /> i 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 /> S IGNEd 0& TITLE: DATE <br /> W PL PL N ON REVERSE SID <br /> A FOR DEPARTMENT USE ONLY <br /> PHASE I d <br />`.APPLICATION ACCEPTED BY DATFI`—/ <br /> ADDITIONAL COMMENTS : <br /> PHASE II 'GROUT INSPECTIO PHASE II F NAL IUSPECTION <br /> INSPECTION BY DATE_Z INSPECTION B DATE/ <br /> EH 1426 - Rev. 12-77' <br />