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r` <br /> SAN JOAQUIN LUCAL HEALTH UISIR Mi ----�- <br /> R_gFFICE USE: 1601 E. Hazelton Ave.', Stockton, CA 95205 Permit No. - 7 7 l <br /> Telephone:. (20.9) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires i Year From- Date Issued ` <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 11862 and the Rules and Regulations .of the San Joaquin Local Health <br /> District. <br /> EXACT STREETIADRESS /�''4�� CITY/TOWN <br /> Owner's Name �i Phone <br /> Address City <br /> Contractor's Name L i c e n s e#.2hre Phone <br /> f IS CERTIFICATE OF worKMAN'S C0111PENSATION I'NSURACIC ON FILE WITH SJLHD? YES 4�1 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION [3 r DESTRUCTION E] <br /> WELL CHLORINATION D WELL ABANDONMENT ❑ OTHER 0 ' .�. <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT ;PRIVY <br /> SEWAGE. DISPOSAL 'FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t ' Cable Tool Dia. of Well Excavation <br /> Domestic/private " Drilled Dia. of Well Casing <br /> Domestic/public 3A Qriven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sealer <br /> Cathodic Protection i; Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical- Surface Seal I tal ed b <br /> PUMP INSTALLATION: Contractor�f <br /> Type of Pump VHP. <br />! PUMP REPLACEMENT: State Work Don ti-a-P� <br /> G. <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Wel,l,. iliameter { Approximate Depth <br /> Describe Material and Proce ure <br /> I hereby certify that I have prepared this appli'cat'ion and that the work will be done in accordanc( <br /> with' San Joaquin County Ordinances , State Laws , `and Ruies 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 J <br /> laws of California. " x� <br /> I..I . WILL CA FOR A G 00 NSP'8-CTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> i <br /> (DRAW PLT 7L N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> : APPLICATION ACCEPTED BY DATE / 7 <br /> ADDITIONAL COMMENTS:­ ! <br /> PHASE II GROUT INSPECTION ,�/ PHASE III FINAL., INSPECTION <br /> INSPECTION BY DATE INSPECTION BYE. DATE. / <br /> FH 11l9h Rav 19_77 y d 1:/_7.8 2M <br />