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SAN JOAQUI4N LOCAL HEALTH DISTRICT <br /># <br /> FF CE USE: 1601 E. hazelton.Ave, , Stockton, CA 95205 Permit No. �- 76 <br /> Telephone: (209) 466 -6781 _ <br /> fA APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7 <br /> k <br /> This` Permit Ex .ire's 1 Year From Date `Issued <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 Regulations of the San Joaquin ,Loeal Health <br />` District. <br /> EXACT STREET ADDRESS /1 ! 7' CITY/TOWN ` <br /> Owner's Name V�ek Phone <br /> .Address I <br /> City. <br /> j Contractor's Name s Li cense#&3 771'*"Phone l <br /> IS CERTIFICATE OF WORKMAN S C011.1m. TI m INSURA"!CE ON FILE WITH SJLHD? YES NO z; <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN0 RECONDITION [] DESTRUCTION C3 <br /> WELL CHLORINATION [] WELL ABANDONMENT ® OTHER 0 a <br /> PUMP INSTALLATION 0 PUMP REPAIR® PUMP REPLACEMENT <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 <br /> Industrial Cable Tool Di'a. of Well Excavation <br /> =Domestic/private Drilled Dia. of Well Casing s d <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 4' Other Information <br /> Geophysical Surface Seal Instal ed b : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> s <br /> PUMP- REPAIR: (State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate 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 , rState 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 f <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 P I 0 GROUTING AND A FINAL INSPECTION. <br /> SIGNED ITLE: Q DATE: <br /> W L T PL ON REVERSE SID <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> + . <br /> APPLICATION ACCEPTED BY � DATE <br /> ADDITIONAL COMMENTS : t <br /> PHASE II GROUT INSPECTION, PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY�'�p DATE S-,�-6 -7 J" <br /> w <br /> H 1426 -Rev. 12-77 1 1-7 Q Om --. <br />