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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 permit No, <br /> Telephone; (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> JDaZ,teIssued , <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 CITY TOWN <br /> Owner's Name 011Phone <br /> Address City <br /> Contractor's Name License Phone /-r-5e t Z2 <br /> IS CERTIFICATE OF WORKIIAN'S COMPENSATION INSUR "!CE ON FILE WITH-SJLHD? YES <br /> TYPE Or WORK (Check) : NEW WELL Z� DEEPEN ❑ RECONDITION ❑ DESTRUCTIONCI <br /> .- <br /> - WELL CHLORINATION. ❑-- -Ef�L -ABANDONMENT Q n OTHER <br /> f PUMP INSTALLATION 5R PUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TA 'EWER LIN PIT PRIVY <br /> SEWAGE <br /> DIS <br /> FIELD_ ?CE SP 0L/S P GE PIT HER ---- <br /> PROPERTY LINE/a- RIVATE DOMESTIC WELL PUBLIC DOMESTIC WE� Lr <br /> INTENDED USE TYPE OF.WELL, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 7i'5i Lgestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 171 Zit;p ,_ <br /> Irrigation Gravel Pack Depth of Grout Sea V <br /> _Cathodic Protection - Rotary Type of Grout �Z lv <br /> Disposal Other Other InformationR <br /> Geophysical Surface Seal Installed by-: � b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. . <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 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 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FI AL INSPECTION. <br /> SIGNED , <br /> TITLE: DATE: <br /> DR W -PL T PL N-ON REVERS SDE <br /> PHASE I <br /> yFTR DEP RTMENT USE ONLY <br /> PPS LICATION ACCEPTED B1z DATE�-r�t� 7 <br /> ADDITIONAL COMMENTS: G w � <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY � �G• DATE �-�' <br /> EH 14 26 Rev. 9/78 `9/7R 99-- 0 <br />