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r SAN JUAQU'IN LOCAL HLAL!N UIS I KIL I <br /> FFICE USE: � 1601 �E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> r� <br /> Telephone:.� phone:. (209)- 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued_f <br /> This Permit Expires l 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 Ordinance No. 1852 and the Rules and Regulations of the SiDan Joaquin Local. Health i <br /> istrict. <br /> EXACT STREET ADDRESS` <br /> CITY/TOWN_ - <br />` Owner's Name 0C AddressPhone — <br /> fCJ ty e <br /> Contractor's Name License#� Phane <br /> E _ <br /> S CE RTIF"ICATE OF 140R01AN S COIIIPENSATION INSURANCE ON FILE WITH SJLHD? YES 1.� <br /> __YPE�OF WORK• (Ch k) : � NEW WELL Cj DEEPEN ❑ RECONDITION —_ + <br /> f T '"."."•�'_"""-"'__:=.�'�•-�.'�-�-y'�-r-�-��..:`vr =-,:�c,�_�--��.�-�,�.r:�:,��_.�--�'..�.�=.-..tom,-=-; <br /> ® DESTRUCTION❑ ��'"" <br /> •-WELL. CHLORINATION � WELL ABANDONMENT a OTHER � <br /> PUMP INSTALLR <br /> TION PUMP REPAIR❑ PUMP REPLACEMENT � . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE Pi-TOTHER 9.u, <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _Industrial Cable Tool Dia. of We11 Excavation W <br /> .� Domestic/private Drilled Dia. of Well Casing , <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation G <br /> Gravel Pack Depth of Grout ,.Seal <br /> Cathodic Protection Rotary, z ,':Type of Grout <br /> Disposal Other A <br /> Geophysical Other Information <br /> Surface Seal Instal ed 'b , <br /> PUMP iNS7RLLATION: Contractor �`'`� <br /> Type of Pump <br /> PUMP REPLACEMENT: 'State Work Done e rev <br /> PUMP REPAIR: `S <br /> ❑State Work Done <br /> DESTRUCTION OF WALL: Well Diameter �' -,T �----- <br /> Describe Material and Procedure Approximate Depth <br /> I hereby certify that I have'prepared, thi:s 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 <br /> permit is issued, I shall <br /> not employ an J <br /> P y y person in such manner as to become subject to Workman's Compensation t <br /> laws of California. " <br /> I WILL CALL FOR A GRO T INSPECTION PRIOR TO GROUTING AND FI L INSPECTION. <br /> SIGNED TITLE: <br /> DR W L T PL N ON REVS SE SIDE DA7E: fz � <br />)HASE I F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 'BY. " <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE II FINAL,, INSPECTION <br /> NSPECTION BY DATE /� � INSPECTION BY <br /> DATE 231�7� I <br /> H 1426. Rev 12-77 _ Gt3 1 <br />