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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. Iq -%6 <br /> Telephone: (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (Complete . In -TriplicateY <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 Local Health <br /> District.4 _ <br /> LXACT STREET ADDRESS p/ CITY/TOWNr �eA� i <br /> s Name o� Phnn .� <br /> Address 1.564 e. City 7 { <br /> Contractor's Na License& Phon S'- - c�&rpt <br /> IS CERTIFICATE OF WORKMAN'S COMIPENSATION INSUgAINCE ON FILE WITH SJLHD? YES v� No <br /> TYPE OF WORK (Check) : NEW WELLCO DEEPEN [] RECONDITION DESTRUCTION( <br /> WELL CHLORINATION Q WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION Nn PUMP REPAIR❑ PUMP REPLACEMENT ( <br /> DISTANCE TO NEAREST: SEPTIC TAN -o/ SEWER LINES' PIT PRIVY <br /> SEWAGE DISP SKAL• FIELDE dF CESOL/SEEPAGE PIT — OTHER <br /> PROPERTY LIN --'PRIVATEDOMESTIC . <br /> --- <br /> N <br /> WELL. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL j CONSTRUCTION SPECIFICA IONS <br /> Industrial Cable Tool Dia. of Well 'Excavatio / <br /> Domestic/private Drilled Dia. of Well Casing i <br /> Domestic/public Driven Gauge of Casinge4, 55 770 <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> M Cathodic Protection 3t�Rotary Type of Grou e ,v <br /> Disposal Other Other Information <br /> Geophysical A .Surface Seal Instal, ed by <br /> PUMP INSTALLATION: Contracts U 42 S&Ilen <br /> Type of Pump H. <br /> PUMP REPLACEMENT: ❑State Work.Done _ <br /> PUMP REPAIR: . _ Q State Work Done <br /> DESTRUCTION OF WELL: .,Well Diameter Approximate Depth <br /> v Describe Material and Proce ure <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: <br />