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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: - - �- 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No -5 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issuec41-7 <br /> (Complete In' 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 compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and' Regdlations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS <br /> Owner's Name CITY/TOWN LCL <br /> Address - - <br /> Phone Q 33 <br /> City, <br /> �s. : <br /> Contractor's Name ` License# Phon <br /> IS CERTIFICATE OF WORKMAN'S COMIPENSATION INSURANCE ON FILE WITH-SJLHD? YES 0 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION C3 DESTRUCTION[ . <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHERS Eg&,p! tc 9J t14e� <br /> PUMP INSTALLATION Q PUMP REPAIR C]- PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIS— OTHER 4 <br /> PROPERTY LIME - PRIVATE DO ESTIC WELL PUBLIC DOMESTIC WE� L�� <br /> - INTENDED USE TYPE OF--WEtJ7— j�©1� CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 5 � <br /> -� Domestic/public _ <br /> Driven Gauge of Casing � <br /> Irrigation ravel Pack Depth of Grout Sea <br /> ____`Cathodic ProtectionRotary Nn 0 E' <br /> isposal OtherOther <br /> I Grout <br /> geophysical Other Information ,_ 6t <br /> t <br /> PUMP INSTALLATION: Contractor Surface Seal installetilbve <br /> Type of Pump H. . <br /> PUMP REPLACEMENT: [7State Work Done <br /> PUMP REPAIR: ❑State Work Done — <br /> DESTRUCTION OF WELL: Well Diameter - � �i <br /> Describe Materia an Pro du Approximate Depth JQ'� ► <br /> I hereby certify that I have prepared this application and that the work will be one in accordant <br /> With San Joaquin County Ordinances , State Laws , and Rules and Regulations ofthe 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 CAL A GRO T LYSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE: DATE: 4 <br /> 7 <br /> DR W PL ON REV RS SIDE <br /> PHASE I OR DEP RTMENT USE ONLY <br />-PCPLIATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: e DATE ,5 /7 <br /> � d � <br /> IiVSPECTION BY <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> DATE <br /> EH 14 26 Rev. 9/78 INSPECTION BY ATS <br /> 9/. 78 2M <br />