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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FFICE USE: 601 E. Hazelton, Ave. , Stockton, CA 95205 Permit No. qrj <br /> lY' Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date .Issued - �-� <br /> This Permit} Ex - ires 1 Year From Date .'Issued <br /> Complete In Tri pl i tate) �� <br /> Application is hereby made to the San Joaquin Local Health. District for a permit� to .construct ' <br /> and/or iTs-tall th0 wwork herein described. This ;appl.ication is made in compliance with San <br /> �oac�J'in County Orrdinance No-:, 1862 and the Rules ,'and Regulations of the San. Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESSCITY/TOWN <br /> 4 Owner' s Name Phone <br /> Address City <br /> Contractor's Name License# Phone <br /> F .IS <br /> IS CERTIFICATE OF WORKMAN-S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL C DEEPEN ❑ RECONDITION ❑ DESTRUCTION[D <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION R�' PUMP REPAIRCI PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK %2 MISEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal p <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by. <br />` PUMP INSTALLATION: Contractor ti 45iel/,/"-c , <br /> Type of PumH.P. <br /> PUMP REPLACEMENT: State Work Done -+ <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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' TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ` <br /> TITLE: ^ DATE: <br /> DR W PLOT N PL ON REVER SIDE ? I <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY G�/ DATE <br /> ADDITIONAL COMMENTS : <br /> INSPECTION PHASE II GROUT INSPECTION <br /> PHASE III NAL SPECTION <br /> ON BY DATEAT <br /> INSPECTION B _ <br /> X1426 Rev.- 12-77 <br />