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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 9- 2A1 <br /> Tel'ephon 209) 466-6781 <br /> LV IAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires. 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. in compliance with San <br /> uoaQui n County Ordinance No. 1862 and the Rules and Regulations egulations of the San Joaquin Local alth ' <br /> Q[ <br /> EXACT STREET ADDRESS- y", 'CITY/TOWN <br /> Owner's Name <br /> Phone Q <br /> Address` ,�`` � � k <br /> t .. City . <br /> Contractor',s Name License# <br /> Phone <br /> IS CERTIFICATE 'OF WORKS MPI S C-OMPENSATIOIN INSURANCE I <br /> !CE Otl FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL � -.DEEPE-Nf] ;RECONDITION ❑ DESTRUCTION.[ <br /> WELL CHLUINATION' WELL` <br /> � ,rO • ABANDONMENT D� OTHER f7 ; <br /> PUMP INSTALLATION 0 PUMP~REPAIR O PUMP REPLACEMENT Q C"111 <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT .PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> ' PROPERTY LINE -. PR CESSP OL/SEEPAGE.PIT OTHER <br /> PRIVATE DOMESTIC WELL 'PUBLIC DOMESTIC WELL 5 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION- SPECIFICATIONS <br /> Indust.ri al <br /> Cable Tool Dia. of:--.-Wel 1 Excavation,-'. OffDomestic/private Drilled Dia. of Well •Casing +� <br /> Domestic/public Driven Gauge of Casing <br />____)(___IrrigationGravel Pack, Depth of Grout Seal <br /> Cathodic Protection __Rotary e r Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Ins <br /> led b <br /> PUMP INSTALLATION: Contractor � � <br /> Type of Pump r <br /> PUMP REPLACEMENT: _ _.❑State\.Work. Done . t <br /> PUMP REPAIR:. - <br /> ` ❑State Work Done - <br /> DESTRUCTION OF WELL: -Well Diameter "= •.' -Describe Material Materia and Procedure Approx'imate -Depth­ F <br /> I hereby certify that I have prepared this application and .that the work will be done in accordance <br /> kith San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <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, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> WILL CA FOR-. A GRO INSPECTION PRIO GROUTING AND A ANAL INSPECTION. f <br />,IGNED TITLE: DATE: <br /> DR L T PL ON REV SE S E <br /> HASE I FOR DEPAR MENT USE ONLY <br /> PPLICATION ACCEPTED BY f 7�1a-�-�c� DATE � <br /> � -•- �'a <br /> DDITIONAL COMMENTS: <br /> 1PHASE II GROUT INSP CTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSP CTION BY <br /> DATE w <br /> 1 1426 Rev. 12-77 ,rte, <br />