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SAN JOAQUIN .LUCAL HtALIH UlbIKIC1 <br /> FOR OFFICE QSt ` 1601 E. Hazeltw -Avow , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6.781 <br /> APPLICATION FOR WELL CONSTRU TION OR PUMP PERMIT Date Issued <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 incompliance with San ". <br /> Joaquin County Ordinance No. 1862 and the Rules and­Regulations of the San- Joaquin ;Local Health,{ <br /> District. a <br /> EXACT STREET ADDRESSCITY/TOWN <br /> Owner's Name a '_ ,. <br /> Phone <br /> Address. <br /> i <br /> Contractor's�Name . . ' 'License# / Phone ��z LO _ <br /> IS CERTIFICATE OF WORKMANS COMPEI'SATIO.j INSURA-1,110E' ON FILE WITH SJLHD? YES No <br /> TYPE OF WORK (Check),: N£W ..W.ELL❑- .-DEEPEN ❑ RECONDIT-I.ON-[-1—DESTRUCT-I-ON-❑'= <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER❑ �] <br /> PUMP INSTALLATION PUMP REPAIR❑. PUMP REPLACEMENT [j, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r� <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 /> -bomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Qriven `" " —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 Sea-1 Instal 'ed <br /> .PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT. ,,, ❑State Work Done F <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximat'e'Depth <br /> Describe Material and 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 Regul-ati-ons 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, 4 shall <br /> not employ any person in such manner as to become sub -9ct to Workman's Compensation <br /> laws of C 1 'fornia. " <br /> I WILL CALL FRA GROUT INSP TION PRIOR TO GROUTING ADA FI AL I& N: <br /> SIGNED i' : ' TITLE: — -- ZA'YAATE: 4ems <br /> E <br /> (DRAW PL T PL N ON REVEW SIDE <br /> FOR DEPARTMENT USr ONLY <br />-PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : 1-07 <br /> _ ' -- <br /> i PHASE II GROUT INSPECTION ��, PHASE III FINAL INSP CTION <br />_INSPECTION 8Y_ } DATE INSPECTION BYL DA E - <br /> EH 1426 Rev. 12-77 1/78 2M <br />