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SAN JOAQUIN LOCAL HEALIH W SIRI'6' <br /> FOP FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone`. (209) 466-6781 <br /> APPLICATION FOR WELL- CONSTRUCTION OR PUMP PERMIT Date Issued / <br /> This Permit. Ex ire's 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 />,:oanui n County Ordinance �Yo .� 1862 and the Rules d Regulations of the San Joaquin Local Health <br /> District. 9�S (� <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name = PhoneG <br /> Address U, C"� City-S-7`aGZt./ 44 <br /> Contractor's Name ' License# Phone <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATIOf INSURA?SCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION[� <br /> WELL CHLORINATION WELL ABANDONMENT ® OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Ul <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 <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump_ ,114a H.P.. <br /> PUMP REPLACEMENT: ❑ State' Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: . Well Diameter Approximate Depth <br /> Describe Material and Pr edure <br /> I hereby certify that I have prepared this application and that the work will be done in accorda ce <br /> Frith San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <br /> dealth 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 INSPECT ON PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE : DATE: 7 <br /> R W PLOT PL N ON REVERSE SIDE f� <br /> FOR DEPARTMENT USE ONLY <br />'RASE I <br /> aPPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE .INSP I Y DATE <br />