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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave; ,• Stockton, CA 95205 Permit No. � Sr . <br /> Telephone: (209-) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 1..7 y <br /> e <br /> (Eomplete -In Triplicate), t <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 /> / P F; <br /> EXACT='STREET ADDRESS -//,I- /fie- �� Q� ": CITY/TOWN <br /> Owner's Name Phone <br /> Address - _ :.—,City <br /> _. . <br /> Contractor's Name VV License# 1 -7i�Phone 1. <br /> IS -CERTIFICATE OF WORKMAN'S C M NSATION INSURANCE ON FILE WITH SJLHD? YES No <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN 0 RECONDITION�Q DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHERfZ] <br /> F PUMP INSTALLATION 0 PUMP REPAIR O PUMP REPLACEMENT'C] - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .`.. PIT PRIVY <br /> .: <br /> SEWAGE DISPOSAL FIELD _CES�OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable -Tool Dia. of We 1 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 Instia7ed b : - <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump H. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR_ (gState Work Done <br /> F' �- <br /> DESTRUCTION OF .WELL: Well Diameter Approximate Depth - <br /> Describe Material and Procedure <br /> I hereby certify 'that I havelprepared 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(1KPEKIQN1PR TO GROUTING AND A-'FINAL INSPECTION. <br /> SIGNS ITLE: r DATE: <br /> (DRAWZW PL ON REVERSE SIDE <br /> FOR PEPARTMENT USE ONLY <br /> 1 PHASE I . 2 <br /> APPLICATION ACCEPTED BY DATE <br /> ; ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 14 26 Rev., 9/78 9/78 -2M . <br />