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SAN JOAQUIN-1LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton eve. }�tockton, CA 95205 Perm)t No. la <br /> Telephone: (209) 466-6781 - -. , <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �- = <br /> This Permit Expires 1 Year From Date Issued <br /> LO 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 Regulations of the San Joaquin Local. Health <br /> District. <br /> EXACT STREET ADDRESS 2 CITY/TOWN <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License# Phone L - <br /> _IL CERTIFICATE OF WORKtlAN`=SCOMMPENSL1011, INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER ❑ <br /> PUMP INSTALLATION ❑ 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 SPECIFICATIOW <br /> Industrial Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. of Weil Casing <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection -t�tRotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑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 fnsubjec <br /> is permit is issued, I shall <br /> not ny person in such manner as to becato Workman's Compensation <br /> law of Ca 'f nia. " <br /> I WILL ALL F GROUT INSP£CTI RIOR TO GROUTINAL IN PE ION. <br /> SIGNED TITLE: DATE: <br /> Irl <br /> DR W PLT L N ON REV.5RSVS DE <br /> PHASE I <br /> FOR DEP RTMENT NLY <br /> APPLICATION ACCEPTED BY DATE —;>f— <br /> ADDITIONAL ADDITIONAL COMMENTS : -- <br /> PHASE II GROUT INSPECTION PHASE- III FIN L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE/ <br /> EH 1426 Rev. 12-77 1/78 2M <br />