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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F ICE USE: 1601 E. Hazelton Ave. , ¢` <br /> Stockton, CA 95205 Permit No, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From 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 /> Loanu-in County Ordinance No. 1862 and the Rules and Regulations of :the- San Joaquin Local Health <br /> District: <br /> EXACT 'STREET ADDRESS <br /> Owner's Name Phone <br /> Address . <br /> Contractor's Name - ' <br /> License# d -77-1-"Phone , ,j..�-Z67-�_ _ <br /> IS CERTIFICATE OF WORKMAN'S CbM NS Tiom INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ . <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION NJ PUMP REPAIR❑ PUMP REPLACEMENT F a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY s" <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL dONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ----4—Domestic/private Drilled Dia. of Well Casing <br /> `Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> - Disposal i Other Other Information <br /> Geophysical Surface Seal Installe=b - <br /> PUMP <br /> b - <br /> PUMP INSTALLATION: Contractor <br /> Type ofd- Pump / H.P. / <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP 4K*R=: <br /> State Work Done <br /> DESTRUCTION OF WELL: Wel I- Diimeter <br /> J <br /> Describe Material ana Procedure Approximate Depth <br /> I hereby certify that I have prepared thisf 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 INS? T ON P IOR TO GROUTING AND A FINAL INSPECTION. {; <br /> SIGNED. TITLE:. ev DATE: Y 7� <br /> D AW PL T N ON REVERSE SIDE + <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE g' <br /> 4DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FI L INSPECTION <br /> fNSPECTION BY DATE INSPECTION BY <br /> 1426 Rev_ 19-77 - --- 1 <br />