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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. Sa <br /> Telephone: (209) 466-6781 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 5'-� ` <br /> f . <br /> _(Complete . In Triplicate). _r <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 i's•made in compliance with San <br />.Joaquin County Ordinance No. 1862 and the Rules and Regulations -of the 'San Joaquin Local Health <br />`,District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> r <br /> Owner's Name Phone <br />-Address City- ...... <br /> Contractor's Name License <br /> / Phoneme T <br />,IS CERTIFICATE OF WORKMAN S COMIPENSATION INSURANCE4N FILE WITH SJLHD? YES 0 <br /> TYPE ,OF WORK (Check) : NEW WELL[X DEEPEN 0 RECONDITION C3 DESTRUCTIOiV� . <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION L PUMP REPAIR❑- PUMP REPLACEMENT Q N <br /> DISTANCE'.TO NEAREST: SEPTIC TAN SEWER LINE PIT PRIVY <br /> SEWAGE DIS PP yrIELD CESSP L/SEEPJGE PIT OTHER <br /> PROPERTY LIN RIVAT�EQO ESTIC WELL•�C PUBLiC DOMESTIC WELL ---� <br /> Y <br /> ; ''INTENDED USE TYPE OF WELL T � � CONSTRUCTION SPECIFICATIONS <br /> 'Industria t <br /> Domestic rivate --Cable Tool Dia. of Well Excavation <br /> /p Drilled Dia: --of Well Casing •� zi <br /> Domestic/public Driven Gauge ofJCasing <br /> Irrigation % Gravel Pack "Depth-of-4Grbut Sea <br /> Cathodi c Protection c3 ? Rotary Type of.Grout <br /> -. .Disposal Others z— '�1' " ! <br /> w , Other-1I.nfarmati an <br /> _Geophysical Surface Seal Insta ed b <br /> ti. <br />]UMP INSTALLATION: -Contractor___--- - . -i-- __ <br /> Type of-mP.ump # <br />'UMP REPLACEMENT: [ State Work Done <br /> y <br /> ❑ <br /> : State Work Done <br /> lump 111M <br /> 3ESTRUCTION OF WELL: Well Diameter <br /> - - Approximate Depth <br /> Desc.rf be Materi a - an' Procedure <br /> hereby 'certify that I have prepared ,this application and that the work will be done in accordance. <br /> lith San .Joaquin County Ordinances,:-State.Laws, and Rules and'1Regulations. of the San Joaquin Local <br /> lealth 'District. Home owner or licensed agent's signature certifies the following: <br /> "I ;certify that in the perfo.rmance-aof -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 /> WILE. CALL FOR A OUT NSp N PRIOR TO -GROUTING AND A FINAL INSPECTION. 10 <br /> IGNED k -0 <br /> TITLE: DATE: <br /> PL ON REVERS�EYS D <br /> OR DEF R I.IENT USE ONL <br /> HASE I - -, ; <br /> P'-LICATION ACCEPTED BY DATE 2 V17 7 <br /> ' <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIT (NAL INSPECTION <br /> dSPECTION BY DATE �"^ /�� INSPECTION BY I/t/ DATE <br /> 1 14 26 Rev. 9/78 ._a- ; 3c/ i7QI OU <br />