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SAN JOAQUIN LOCAL HEALTH DISTRICT OFFFOR ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.? -3/3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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. 1862 and the Rules and Regga�alatio s of the an Joaquin Local Health <br /> District. ''Gs/ ���'" i� 'I"��r.:1WX U1 <br /> EXACT STREET A :DR SS `# ' / ' ' �` '" : /'� '�` � ilet TOWN <br /> Owner's Ne <br /> � ' �'" ' Phone <br /> Address kie 1 '°w city 'se-AXV ow, <br /> Contractor's Name___ ��'" � ", �'` Li cense# T7,41 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES '�" NO' <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN ❑ RECONDITION [D DESTRUCTION[i �. <br /> WELL CHLORINATION WELL ABANDONMENT 0 OTHER E <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT C� `�- <br /> DISTANCE TO NEAREST: SEPTIC TANK " `SEWER LINES PIT PRIVY �^ <br /> SEWAGE DISPOS +FIELD CESSPOO /SEEPAGE PIT OTHER 6,0} <br /> PROPERTY LINE - PRIVATE D MESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 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 Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed . <br /> PUMP INSTALLATION: Contractor `' 'F'' " ^' ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material 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 /> I WILL C L FOR,A GRV INSPECTIO PRIOR TO GROUTING AND& FINAL INSPECTION. <br /> SIGNEQ y ,a,. TITLE:- �r"_ r DATE:' " <br /> ,Z-P, <br /> __(DRAW N ON REVERSE SIE <br /> FOR DE RT ENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEDBYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II PRUT INSPECTION PHASE III- FINAL - INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATE <br /> EH 14 26 Rev. 9/78 9/78 2M <br />