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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 1� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 0��I,-2 g <br /> This Permit Ex fres. 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 '' ; S.; CITY/TOWN ^; <br /> Owner's Name _ ..w j, n. :�: ., Phone ~J6 " <br /> Address �` � .. . , .'<.. ; " City 5,i " <br /> Contractor' s Name Phone Vt. t = �7 <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATIO1 I4URANCE OM FILE WITH SJLHD? YES NO g <br /> TYPE OF WORK (Check) : NEW WELLS DEEPEN ❑ RECONDITION ❑ DESTRUCTION[D ! <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER [ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT E] t <br /> DISTANCE TO NEAREST: SEPTIC TALK SEWER LINES PIT PRIVY C"� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/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 Well Excavation ". <br />-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 Other Other Information i <br /> Geophysical Surface Seal Installed by: <br />)UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />'UMP REPLACEMENT: [] State Work Done <br /> LUMP REPAIR: ❑State Work Done <br />]ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />[ hereby certify that I have prepared this application and that the work will be done in accordancf <br /> vith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> lealth 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 />[ WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> i IGNED _ ;tet . „ TITLE: DATE: ,- <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEP RTMENT USE ONLY <br />'RASE I >' <br /> IPPL ICATION ACCEPTED BY �" . DATE ' 7 <br /> kDDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION ' <br /> NSPECTION BY DATE INSPECTION BY DATE <br />