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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone:. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued o_ <br /> This Permit Expires 1 Year From 'Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the 'San Joaquin Local -Health District for permit to construct <br />' Application- is <br /> install the work herein described. Thisapplicationis made incompliance with San <br /> uoaquin County Ordinance . No..,. 1862 and the Rules and Regulations of the San Joaqui-n Local Health <br /> Oistryct. <br />' EXACT STREET ADD SS �Ca CITY/TOWN <br /> Y <br /> Owner' s Name Phone <br /> Address '�C] City <br /> Contractor's Name License# 2 ,, / Phone = f <br /> IS CERTIFICATE OF W 1AtJ S ENS INSURA*ICE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION C# WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION X PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria1 Cable Tool Dia. of Well Excavation W <br />=Domestic/private 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 b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump , CAJ,_- —._ _ H.P. ' <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done f <br /> DESTRUCTION OF WELL: Well Diameter -- �- Approximate Depth <br /> Describe Materia and Procedure <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 />[ WILL CAL GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />>IGNE TITLE: DATE: <br /> DR W PLOT PL N ON REVE SE SIDE <br /> FOR DEP RTMENT USE ONLY <br /> 1HASE I <br /> kPPLICATION ACCEPTED BY DATE <br /> ,Z_5-- <br /> ! <br /> kDDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III AL INSPECTION <br /> NSPECTION -BY DATE INSPECTION BY DATE <br /> H 1426 R - , 1-70 I)XIF <br />