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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFI'CE USE: 160.1 E. Hazelton Ave. , Stockton, CA 95205 Permit No. �2 . <br /> Telephone: .(209) 466-6781 Date Issued I <br /> APPLICATION .FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires 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 /> 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 /> Phone " <br /> Owner' s Name <br /> City <br /> Address .r "` , <br /> Li cans Phone `s " <br /> Contractor' s Name - <br /> IS CERTIFICATE OF WORKMAN'S C0";PENSATI01,,1 It9SURA"1C£ Ml FILE,1r1ITI1 SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLS DEEPEN ❑ RECONDITION [ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT.❑ OTHER ❑ - <br /> PUMP INSTALLATION O PUMP REPAIR❑ „ "PUMP REPLACEMENTI� <br /> DISTANCE TO NEAREST: SEPTIC TANK;-- SEWER LINES PIT PRIVY, <br /> p SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT:s OTHER <br /> ,' , <br /> PROPERTY LIN �RIVATE DOMESTIC WELL �' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL `'CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable. Tool Dia. of We 1 Excavation <br /> A omestic/private Drilled Dia. of,Well Casing <br /> Domestic/public' driven Gauge of Gasing <br /> Irrigation Gravel Pack Depth of� Grout Seal <br /> Cathodic Protection Rotary1TypeRof Grout " <br /> ' Disposal 'Other �' Other Informatio <br /> - Geophysical Surface Seal Installed b <br /> ,. PUMP"INSTALLATION: Contractor H.P. <br /> t Type of Pump ------------- <br /> ' PUMP REPLACEMENT: []State Work Done <br /> I PUMP' REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate. Depth <br /> Describe Materia and Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> Fr; <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 /> mit is issued, I shall <br /> "I certify that in the performance of the work for' which this per <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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> DATE: <br /> SIGNED—, TITLE- <br /> DRAW <br /> TDRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` DATE.// _. <br /> APPLICATION -ACCEPTED BY ` <br /> ADDITIONAL COMMENTS : <br /> ' R "PH;4SE III ;FINAL INSPECTION <br /> PHASE II GROUT INSPECTION•. DATE <br /> INSPECTION BY DATE INSPECTION BY <br /> s <br />