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FFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 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 /> This Permit Ex ire's I Year From Date Issued <br /> Complete In Triplicate <br />► Application is hereby madelto 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 /> i �oac�u�n County Ordinance "ro. 1862 and the -Rules and Regulations of the San Joaquin Local Health <br /> Elistr;ct. <br />' EXACT STREET. SS <br /> Owner's Name � � CITY/TOWf <br /> Phort�� <br /> Address -� � . .. cit <br /> Contractor's Na <br /> %<. *'n Licens_e� _ 'Phone �' <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO,1 INSURAINCE ON FILE WITHSJLHD? �A ��� <br /> YES NO �. <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN El RECONDITION DESTRUCTION[} <br /> O IRECONDITION - <br /> � <br /> WELL CHLNATION p� /�ELL ABANDONMENT Q OTHER 0 ' <br /> PUMP INSTALLATION EV PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY � 4 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ' <br /> _Industrial TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Welation <br /> omestic/private Drilled pia, of Well Casing <br /> _Domestic/publicDriven <br />.Irrigation - Gauge of Casing <br /> Gravel Pack Depth of Grout Seal s <br /> Cathodic Protection Rotary T <br /> Disposal Cher the of Grout <br /> Geophysical Other Information ; <br /> I Surfac `,Seal Installed b <br />'UMP, INSTALLATION: Contract <br /> Type of Pump !J / H. t. <br />'UMP REPLACEMENT: ❑State Work Done <br />'UMP REPAIR: ❑State Work Done ' <br /> i <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materlar and Procedure Approximate Depth ; <br /> hereby certify that I have prepared this application <br /> ith San Joaquin County Ordinances , State Laws , and RulestandaRegulationsthe workwoflthe SanEJoaquin oLocale <br /> ealth District. Home owner or licensed agent' s signature certifies the following: <br /> certify that in the performance of the work for which this permit is issued, I -shall <br /> not employ an i <br /> p y y person in such manner as to become subject to Workman's Compensation <br /> laws of alifornia." <br /> WILL CAL WR A GROUT INSPECTION PR. OR TOG iJTING AND A . hfAL INSPECTION. <br /> fGNED <br /> TITLE: f <br /> DATE• �E <br /> 'D T P N ON REV pE <br /> LASE I FOR DE NT USE ONLY <br />'PLICATION ACCEPTED 8Y <br /> iDITIONAL COMMENTS : DATE <br /> PHASE II GROUT INSPECTIONPHASE III FINAL INSPECTIQN <br /> SPECTION BY DATE INSPECTION BY <br /> DATE <br /> 1426 , Rev. 12-77 <br />