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SAN =JOAQUIN LOCAL.,HEALTH DISTRICT <br /> FFICE.USE: 1601 E. Hazelton AVe�.� 5 tockton, CA 95205 Permit No. �. <br /> f_ Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> 7. <br /> Date Issued <br /> This Permit .Ex i`res .1 Year From Date' Issued <br /> Complete In Triplicate <br />' Application is hereby made to the San Joaquin Local Health District fora permit to construct $ <br /> and/or install the -work herein .described.. This application .is made in..compliance with San <br />` �'aaquin 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 Phone ` <br /> Address- 4,0 f/ City <br /> Contractor's Name License# Phone -- <br /> IS CERTIFICATE OF WOROMAIPS FILE WITH SJLHD? YES- NO - - <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ -DESTRUC-T-1-ON-0— <br /> WELL CHLORINATION ❑_ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> IIDISTANCE 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 T CONSTRUCTION 'SPECIFICATI NS <br /> Industrial , Cable-,Triol Dia-.. of Well Excavation Az <br /> 1/Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casih6- <br /> Irrigation Gravel Pack Depth of Grout Seal � s <br /> Cathodic Protection Mary Type of Grout <br /> Disposal Other Other Information•.- f t <br /> Geophysical Surface Seal Installed b <br />; PUMP INSTALLATION Contractor W <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:,' ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> kDESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure '} <br /> tI 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-Rul-es 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 empl person in such manner as to become subject to Workman`s -Compensation <br /> la of Calif rnia." <br />' I WI CALL FOR GROU �PETION R -TO GROUTING AND A FINAL INSPECTION. .� <br /> SIGN 3 TITLE:;.. r i DATE: <br /> f <br /> MRAW PLOT PLAN ON REVERSE SIDE <br /> t <br /> f FOR DEPARTMENT USE ONLY <br />' PHASE I <br />° APPLICATION ACCEPTED 8Y _ DATE,57 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL- INSPECTION <br /> 1INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 Rev: 12-77 . 1/78 , 2M <br />