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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -- FOB_GFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. _J <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 Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS'� {? C ITY/TOWN j'jar�, is <br /> , <br /> Owner's Name Phone <br /> Address <br /> City <br /> Contractor's Name 2 , � ru License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA"ECE N FILEEWITH-SJLHD? YES N0 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN Q RECONDITION ❑ DESTRUCTION13 <br /> WELL CHLORINATION Q WELL ABANDONMENT p OTHER 0 � <br /> PUMP INSTALLATION Z�- PUMP REPAIR[]-_ PUMP REPLACEMENT Q 11 <br /> 1 <br /> i <br /> DISTANCE TO NEAREST: SEPTICTTANK - - SEWER LINES � F PIT PRIVY <br /> SEWAGE DISPOSAL FIELD/ A25f CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN -4 PRIVATE DOMESTIC ELL.-a..a- PUBLIC D MESTIC WE <br /> INTENDED USE TYPE OF WELL, CONSTRUCTION SPECIFICATIONS <br /> _Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drill Dia, of Well Casing <br /> _Domestic/public Driven Gauge of Casing <br /> Irrigation Grave k Depth of Grout Sea <br /> ---____Cathodic Protection R Type of Grout - <br /> Disposal .v 0 r Other Information <br /> GeophysicalCN Surface Seal Installed b : <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpILL- <br /> A4 ,� -f h H.P. <br /> PUMP REPLACEMENT: <br /> []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and ce ure <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. " , a , <br /> I WILL C LL FOR A GROUT INSPECTION PRIOR TO GROUTING AND__A FINAL INSPECTION. <br /> SIGNED TITLa 10 <br /> DATE: 3 <br /> 5 -R PLO L N ON REVERSE SIDE - <br /> PHASE I FOR EPA MENT USE ONLY <br /> APPLICATION ACCEPTED -BY , Y DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II�SOUTINSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br />=H 14 26 Rev, 9/78 DATE <br /> _ 9/78 2M . <br />