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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rFICE-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 <br /> S This Permit -Expires 1 .Year From Date Issued <br /> + Complete In Triplicate <br /> Application is . hereby made to the San Joaquin Local Health Di.strict for "a permit to construct <br /> and/or install the work herein described. This application is made in dompli-a'nce with San <br /> �oan;lin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br />( EXACT STREET ADDRESS 7 `'-`Q CITY/TOWNsa <br />, Owner's Name Phone <br />;.Address <br /> City <br /> Contractor's Name License# "-�S hone <br />? IS CERTIFICATE-OF WORKMAN'S. COMPENSATION INSURANCE ON- FILE:`WITH SJLHD? YES NO <br />"TYP OF WORK (Check) ;,NEW­WELLC� DEEPE�I,CI.: �RECONDITION:Q � DESTRUCT�IONRC� - �-- - ='V . <br /> 'WELL CHLORINATION Q WELL ABANDONMENT Q OTHER Q (�;; <br /> PUMP INSTALLATION [' PUMP REPAIR Q PUMP REPLACEMENTEI l <br /> DISTANCE TO NEAREST: SEPTIC TANK td SEWER LINES PIT PRIVY <br /> SEWAGEDISPOS L FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LI'NE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE j TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ,Cable Tool Dia. of Will—Excavation <br /> Dia. of Well Casing ,Q t <br /> Domestic/public Driven Gauge of Casing - � <br /> rrigation Gravel Pack Depth of Grout Seal s <br /> Cathodic Protection rotary Type of Grout e-7 . I <br /> Disposal i Other, Other Information W <br /> - Geophysical i �, Surface Seal Installed b s <br /> PUMP.INSTALLATION: Contractor <br /> Type of Pum <br /> PUMP REPLACEMENT: ❑State Work Donee;- <br /> PUMP REPAIR: <br /> QState Work Done <br /> IG <br /> DESTRUCTION OF WELL: Well�`Diameter � Y ` <br /> _ - -Approximat-e'-DepthDescribe Material and --Pro-ce ure- <br /> I hereby certify that I have prepared this application,and' that the work will be done in accordance <br /> Withan 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 /> t <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. " -WILL CALL F R A GROUT INSPECTION PRIOR •TO GROUTING AND A.FINAL INSPECTION. <br /> r <br /> LIGNED ,� TITLE: -\ �j" <br /> -�� . . . DATE: <br /> DR W L T.- PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY "'`� DATE Z <br /> ADDITIONAL COMMENTS : g <br /> PHASE II GROUT INSPECTIO PHASE III FINAL INSPECTION`' <br /> INSPECTION BY DATE`r2---Z-4-2�7 INSPECTION BY DATE <br /> V14-6 Rev_ 12=77 <br />