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*goo '� SAN JOAQUIN LOCAL HEALTH:D,ISTR`ICT <br /> FICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 y / <br /> Telephone: (209) 466-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (Complete In Triplicate). <br /> Application is hereby made to the San Joaquin Local Health District -for a permit to construct, <br /> and/or- instal.l: the work herein described.. This application is made inicompl,iance 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 h CITY/TOWN. <br />:Owner's Name ,a Phone <br /> Address City - •� <br /> Contractor's Nam License# WH- Phone —'ZC <br /> IS CERTIFICATE -OF WORKMAN'S C i0r CATION INSURANCE ON FILE WITH SJLHD? YES O <br /> TYPE OF WO[K (Check) : NEW WELL L DEEPEN 0-- RECONDITION DESTRUCTION[n <br /> WELL CHLORINATION 0 WELL-ABANDONMENT Q OTHER 0 � <br /> PUMP INSTALLATION- [] PUMP REPAIR K). PUMP REPLACEMENT ❑ 2 <br /> .DISTANCE TO NEAREST: - SEPTIC TANK SEWER LINES. .". _ ... .,PIT PRIVY <br /> SEWAGE DISPOSAL -FIELD j CESSP�L/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 /> cK rri.gation Gravel 'Pack Depth of 'Grout Sea <br /> Cathodic Protection Rotary Type of Grout m" <br /> R Disposal Other Other Information <br /> Geophysical M Surface Seal Insta ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 7 ✓ <br /> PUMP REPLACEMENT: CIState Work Done .n ` . <br /> PUMP REPAIR: CKState Work Done &&Z C- <br /> DESTRUCTION OF WELL: Well Diameter , Approximate Depth <br /> Describe Materia 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 performanceof 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."! n <br /> I WILL CALL FOR A GROUT IN CT N RI`QR TO GROUTING AND A FINAL INSPECTION. <br /> SIGN ;� ITLE: DATE: f . <br /> DRAW-;P OT PI ON REVERSE SIDE) . ` <br /> FOR DEPARTMENT U E ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIiI, FJ AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATA ` <br /> EH 14 26 Rev. 9/7$ 9/78 <br />