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A <br /> SAN JOAQUIN ;L -CALj EALTH DISTRICT <br /> OFFIAE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209)466-6781 (- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> This P_ermit .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 /> Joaquin County 0rdinance'iNo. .1862 :and the Rules and Regulations of the San ,Joaqui,n Local Health <br /> r�istrict. <br /> EXACT STREET ADDRESS <br /> CITY/TOWNztaIo.►, <br /> Owner's Name <br /> Phone <br /> City - . . . , <br /> Ad d.r.e s s — <br /> Contractor' s Name License# Phone <br /> IS' CERTIFICATE' OF WO0,Kt4t '5 COMPENSATION IOCIUDANC ON FILE WITH SJLHD? YES 'JO <br /> TYPE OF WORK (Check) : NEW WELL Q6 DEEPEN E] RECONDITION.[" DESTRUCTION[D <br /> WELL CHLORINATION Q WELL ABANDONMENT Cl OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: r SEPTIC TANS_ SEWER LINES j� PIT PRIVY <br /> SEWAGE DISPOSALL FIELD r CESSPOOL/SEEPAGE PIT OTHER -� <br /> PROPERTY LIN90-11PRIVA E DOMESTIC WELL,/,&—'-- PUBLIC DOMESTIC WELL — <br /> INTENDED USE TYPE OF' WELL CONSTRUCTION SPECIFICATIONS o[` <br /> ool- Dia. of Well Excavation ' 1- <br /> Industrial Cable-To� <br /> � <br /> Domestic/private Drilled Dia. of Well Casin g <br /> Domestic/public ; k Driven Gauge of Casing <br /> IrrigationGravel Pack Depth of Grout Sea!_ n <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed b <br /> PUMP INSTALLATION: Contractor <br /> �Type ,of Pump H.P. --- <br /> PUMP REPLACEMENT: ]State Work Done <br /> PUMP REPAIR: ❑State Work Done <br />' DESTRUCTION OF WELL: Well Diameter j Approximate Depth <br /> iDescribe Materia an Procedure 11 <br /> I hereby certify that I ,have prepared-this application and that the work will be done in accordant <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 FORA ROUT��. S TgYPRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED: w TITLE: DATE: Cl <br /> iM DRAW PLOT PLAN ON REVS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I j� <br /> CAPPLICATION ACCEPTED BYE DATE <br /> ADDITIONAL COMMENTS: il <br /> PHASE lV41 GROUT INSPECTION PHASE III -FINAL I SPECTION <br /> INSPECTION BYDATE Z_f 1-7 � _ INSPECTION BY DATE �' 4. <br />