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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />__FOR OFFICE USE: 1601 E. Hazelton Avg`. , ocktonA_,_9.5.2.05 Permit No.r7`�uG <br /> Telephone; . t?09) 465, 6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issuec5_/ 7 2 _ <br /> This Permit E ires 1 Year From Date Issued �� s <br /> Complete, ln Triplicate <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 ,.compli-ante with San <br /> ,'oaoui n County Ordinance No., 1862 and the Rules and Regulations of the San ,Joaquin Local Health � <br /> D,istr'ct. <br /> CITY/TOWN <br /> EXACT STREET ADDRESS dZ22 <br /> { <br /> Owner' s Name ' Phone <br /> i <br /> Address j City <br /> Contractor's <br /> Name <br /> License Phone — 1J <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"m IPISUAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : ' fNEW WELL% DEEPEN ❑ RECONDITION ❑ DESTRUCTION[°] ' <br /> WELL CHL RINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> 63 <br /> DISTANCE TO NEAREST-: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> f INTENDED USE TYPE OF WELL - c. �_ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation s G <br /> ,-domestic/private Drilled Dia. of Well Casing_ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of-Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal } Other Other Information <br /> Geophysical Surface,Seal Installed b <br /> kPUMP INSTALLATION: Contractor <br /> Type of Pump <br /> � f <br /> PUMP REPLACEMENT: ❑State Work Done r f <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL1. Well Diameter --' Appioximate. 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 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-GROUTINGIAND A FINAL INSPECTION. <br /> SIGNED <br /> ' TITLE: DATE: <br /> (DRAW PLOT PLAN ON REVERSE,SIDE . <br /> .` FOR DEPART M Nl- USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � < DA1:g <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION a PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _ -�� <br />