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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. - <br /> ` Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -13-? <br /> This Permit Expires 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 t e San Joaquin Local Health <br /> District. <br /> EXACT STREET AQDRESS CITY/TOWN <br /> Owner's Name ' Phone <br /> Address S ' -- City- 1z zz <br /> Contractor's Name .,; n Li cense#.OBAY Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION [] DESTRUCTION <br /> WELL CHLORINATION WELL ABANDONMENT 0 OTHER❑ °0 <br /> PUMP INSTALLATIONM PUMP REPAIR❑ PUMP REPLACEMENT );�' <br /> r.. <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout , <br /> Disposal Other Other Information <br /> Geophysical Surface Seal I to ed by: <br /> PUMP INSTALLATION: Contractor ,a-Z - c <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: -r M State Work Don ' <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 accordanc <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 CALL FOR A GROU NSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED - TITLE: DATE: <br /> ADRAW PLT L N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 2 <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE /vim INSPECTION BY W DATE <br /> 78 2M <br />