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- SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> gEFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA } 95205 Permit No. <br /> Telephone: (209) 466-6781 02 3 <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 • CITY/TOWN` _ = ,� <br /> 'Owner's Name ' = — - <br /> ��. Phone–..p "e <br /> Address– <br /> City :: s v <br /> Contractor's Name . 't i � _ License# Phone_ 9' < ,� <br /> IS CERTIFICATE OF WORKMAN'S COMiPENSATIOMd IMdSURA"fCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL CI DEEPEN 0 RECONDITION [2 DESTRUCTION[ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> tN <br /> PUMP INSTALLATION [ I PUMP REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP L/SEEPAGE PIS— OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL— PUBLIC DOMESTICEfELLLL — <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial " Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: D State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 1. ,� Approximate Depth '. <br /> Desri be Maria 41Fand <br /> Pa.4ru'Io<L cf e. iur. e'..y. r t _+•�-. �~ . ' <br /> t <br /> : N ""We, <br /> .? ♦r w i a""�_�y. <br /> hereby certify that I have prepared thisVapplication -and that the work will .be done in`aceardaI <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Loc' <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 GROUTINSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. _ <br /> SIGNED'. ,. ';.. TITLE: DATE�: �'�, ,>' , <br /> D P TPLVN ON REVERSE SIVE <br /> PHASE I FOR DE RTMENT US I <br /> APPLICATION ACCEPTED BY g x <br /> ADDITIONAL COMMENTS: . <br /> �,� DATE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE II FINAL INSPECTION// <br /> DATE INSPECTION BY DATE 7!� <br /> EH 14 26 Rev. 9/78 9/72 ,; <br />