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SAN JUAQUlN LULAL HtALIH UISIKILI <br /> FFICE USE: 1601 E. Hazelton Au,, , Stockton, CA 95205 [Date <br /> it No. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Trip icate <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. <br /> EXACT STREET ADDRESS , L <br /> Owner's Name tphoneTOWN <br /> � <br /> Address Ci ty <br /> Contractor's Name LicensefyPhone �f <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAN 4 ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELLM DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ N� <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINEC�Z-f PIT PRIVY n <br /> SEWAGE DISP SAIL FIELD SSP OL/SEEPAGE PIT OTHER <br /> • PROPERTY LIN&S.4PRIVATE DOMESTIC WELL�E PUBLIC D MESTIC WELL - �$ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing r <br /> Irrigation Gravel Pack Depth of Grout 'Se-7777 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. , <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 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 C FOR A GROW INSPE 0 10 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> (DRAW PLOT N ON REVERS- IDE <br /> FUR-T-E­PARTMENT USE ONLY <br /> PHASE I <br /> PPLIC TION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II OOUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY &0 DATE /Q i6 T <br /> EH 1426 Rev. 12- 7 1/78 2M <br />