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C6#*1lb/rWe' i <br /> FFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, CA 95205 Perm7No. - ��Telephone: (209) 466-6781 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Datell <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 Local Health <br /> District. <br /> EXACT STREET ADDRESS /S 4-"D S K y SQL <br /> CITY/TOWN_ ,:�h <br /> Owner's Name <br /> Address Phone - <br /> — <br /> Ci ty L� % �� <br /> Contractor's Name License—# d37kPhone__ <br /> IS CERTIFICATE OF WORKMAN'S COQ ��- <br /> ENSATION INSURANCE ON FILE WITH SJLHD? YES S'� N0 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN C{ RECONDITION [2 DESTRUCTION[� <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER [] <br /> PUMP INSTALLATION 5J PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY ` <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> _______Industrial Cable Tool CONSTRUCTION SPECIFICATIONS <br /> Domestic/private Dia. of We Excavation ` <br /> Domestic/public Drilled Dia. of Well Casing <br /> Irrigation Driven Gauge of Casing <br /> Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary T <br /> Disposal Other YPe of Grout <br /> Geophysical Other Information <br /> PUMP INSTALLATION: Surface Seal Insta ed by• <br /> Contractor <br /> Type of Pump ' <br /> PUMP REPLACEMENT: H• �" <br /> Q State Work Done <br /> PUMP [R State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe MateF-Idl and Procedure Approximate Depth <br /> I hereby certify that I have prepared this application and that the work <br /> w be <br /> with San Joaquin County Ordinances, State Laws, and Rules and Regulations oflthe SaneJon accordance <br />'�iealth District. Home owner or licensed agent's signature certifies the following: <br /> aquin Local <br /> "I certify that in the performance of the work for which this permit is issuedI shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. <br /> f WILL CALL FOR A GROUT INSPE ON PR TO GROUTING AND A FINAL INSPECTION. <br />;IGNED <br /> ONT : — <br /> DATE <br /> F REVERSE �E <br /> HASE I �p <br /> SE NLY <br /> PPLI ATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE 7 <br /> PHASE II GROUT INSPECTION <br /> VSPECTION BY DATE PHASE III FINAL INSPECTION <br /> 1 14 26 Rev. 9/78 INSPECTION BY DATE <br /> : <br /> 9/7. _ M <br />