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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> QR ' FFICE USE: I 1601 E. Hazelton Ave:, Stockton, CA 95205 Permit No.Z is-�o <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ <br /> This Permit.-Ex fres 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 cons-truct <br /> and/or install the work herein.-described. This application- is made- in compliance with San <br /> uoanuin: County Ordinance pyo: 1862 °and the Rules and Regulations of the San Joaquin Local Health <br /> DistriC,-. q <br /> EXACT STREET ADDRESS oC Y/TOW <br /> Owner's Name Phone <br /> Address fl ..City <br /> Contractor' s Name <br /> "IS CERTIFICATE OF WORKMAIVCOMPENSATINN INSURANCE ON FILE WITH SJLHD? YES NO 1 <br /> TYPE OF WORK (Check) : NEW WELL Et— DEEPEN Q RECONDITION ❑ DESTRUCTIONC2 <br /> WELL CHLORINATION Q WELL ABANDONMENT OTHER 0 <br /> PUMP INSTALLATION a— PUMP REPAIR❑ PUMP REPLACEMENT [I <br /> DISTANCE TO NEAREST:. SEPTIC TANK -SEWER- LINES 4�0 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTICS WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE � _ TYPE OF WELL w CONSTRUCTION `SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well' Ekcava tion" <br /> =Domestic/privated Drilled Dia. of Well Casing- .� <br /> Domestic/public Driven - 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 Seal Installed by: <br /> PUMP INSTALLATION: Contractor {� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> QState"Work "Done' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth '. <br /> Describe Material and Procedure <br /> I� <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 employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR T GROUTING AND A FINAL INSPECTION. <br /> SIGNED i� TITLE: DATE. dcZ / <br /> .:4 <br /> (DRAW NoT PITN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � � " <br /> APPLICATION ACCEPTED BY1M �- DATE 0f, <br /> ADDITIONAL COMMENTS : 1P <br /> PHASE II' GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION-BY 1p DATE ,INSPECTION Bl' DATE' r <br />'FH 142E Pou 19-77 n �( 1 17A _2M <br />