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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued S_ -7 <br /> This Permit Expires I. Year From Date Issued ' <br /> Complete Ire 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 />,oaouin County Ordinance 1,o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Distr�ct. <br /> EXACT STREET ADDRESS — f CITY/TOWN <br /> Owner' s NameE= Phone 3 <br /> Address City l ,4.-L> <br /> Contractor' s Nam r--j ,�, License jt 9cam_ Phone '`7 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURX110E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION [PUMP REPAIR❑ PUMP REPLACEMENT ❑ oC <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 (P <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br />--L --somestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ <br /> Z —Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical —Surface Seal Installed by: <br /> PUMP INSTALLATION: Contract r y/a (� c <br /> Type of Pump <br /> PUMP REPLACEMENT: p State Work Done <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 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 emplo any person in such manner as to become subject to Workman's Compensation <br /> laws of alifornia." <br /> I WILL CAL FOR A GROUT INSPECTION RI R TO G OUTING AND fi,,4AL INSPECTION. <br /> SIGNED TITLE:Z/ DATE '~ / <br /> DRAW P ON REV E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE!j�, ]�- 7 <br /> EH 1426 Rev. 12-77 1178 2M <br />