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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -= $ICE USE: 1601 E. Hazelton Ave. , <br /> F Stockton CA - 95205 Permit. No. <br /> =a Telephone: (209) 466-•6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued_ <br /> (tomplete 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: /10_ All <br /> f3,��dri <br /> ;EXACT STREET ADDRESS .� CITY/TOWN_�� ,,. • . , <br /> ,Owner's Name __ „ <br /> c' '1 <br /> Address Phone —$5' CP. <br />.: � <br /> '.Contractor's Name City <br /> p License# Phone ; <br /> c : <br /> .IS C€RTIFICATE OF WORKMAN'S GO"iPENSATIOrJ INSURA.1 E ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION 0 d . <br /> k WELL CHLORINATION 0 WELL ABANDONMENT a OTHER( <br /> PUMP INSTALLATION ��- PUMP REPAIR 0- PUMP REPLACEMENT Q � E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES d0' IT PRIVY z <br /> SEWAGE DISP SIELD ,m CESS L/SEEPAGE P OTHER <br /> PROPERTY LINEV PRIVATE—DOMESTIC WELL/C&`—t— PUBLI MESTIC WEL � <br /> �—I'NTENDED-USE " <br /> TYPE OF.WELL._ �'CONSTRUCTION SPECIFICATIONS <br /> Industria Cable Tool Dia. of Wel Excavation <br /> mastic/private ` <br /> Drilled Dia, of Wel ] Casing # <br /> .. stir/public Driven ' <br /> Irrigation Gauge of Casing <br /> Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotar <br /> Disposal y Type of Grout ', -. <br />, _Geo h sical ' Other --Other Information y t. <br /> p y Surface Sdal 'Insta ed <br /> RU4/INSTALLATION: Contractor <br /> -• <br /> 4141. Type of Pump H: <br /> PUMP REPLACEMENT • • <br /> []State Work Done <br />"UMP REPAIR: <br /> CState- Work Done <br />}:ESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br />` hereby��ertify that I have prepared this application and that the work will <br /> h San Jo be in <br /> d taquin County Ordinances , State laws , and Rules and Regulations of the San eJoaquin oLocal <br /> e <br /> lealth 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,. 1 shall <br /> not employ any person. in such manner 'as to become subject to Workman's Compensation <br /> - Laws of California. ” <br /> r <br /> 'WILL CALL. FOR A. GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> I1GNtu TITLE:' <br /> DATE: ' <br /> R PL L N ON REVERSE SIDE <br /> 4ASE I R DE RT EN USE ONLY <br />':PL CI ATION ACCEPTED B <br />)DITIONAL COMMENTS: DATE 2 1917? <br /> r <br /> .,PHASE I.I T INSPECTI N <br />!'SPECTION,BY: DATE HASE III FINAL ' INSPECTIO <br />! 14 26 Rev. 9/78 <br /> INSPECTION BY DATE - ' <br /> .� �.. Q 7 <br />