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E SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. g� <br /> € Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued iL-ice>g' <br /> ' (Complete In Triplicate). <br />. Application is hereby made to the San Joaquin Local Health ,Distr.ict 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. 11862 and the Rules a d Regulations of the San Joaquin Local ' Health <br /> District. <br /> EXACT STREET ADRESS CITY/TOWN X�� <br /> :Owner's Name Phone <br /> Address <br /> City— <br /> Contractor's Name p Li cense# Phone_ <br /> -IS CERTIFICATE OF WORKMAN'S COM"PENSATION INSURA?!CE ON FILE WITH SJLHD? YES N0 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION r-1 � <br /> WELL CHLORINATION-Q WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION E3' PUMP REPAIR 0 PUMP REPLACEMENT [� � <br /> DISTANCE TO NEAREST: SEPTIC TANK ISb SEWER LINES.Zpo .' PIT PRIVY <br /> SEWAGE DISPOSAL IELD , CESSP E/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> , Industria Cable Tool Dta,of Well Excavation <br /> �^Domestic/private Drilled Dia. of Weil Casing <br /> Domestic/public Driven Gauge of^Casing / <br /> Irrigation Gravel Pack L Depth-of Grout Sea a <br /> Cathodic Protection _ _Rotary Type of Grout _ <br /> Disposal Other <br /> Other Information ' <br /> _Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor 6. . .- <br /> Type <br /> ' .Type of Pump y, i <br /> PUMP REPLACEMENT: []State Work Done 4 ._ <br /> PUMP REPAIR: ,.. . Q State Work' Done <br /> DESTRUCTION OF WELL: Well Diameter �y �P <br /> - MApproximate Depth <br /> Describe Material and Proce ure <br /> I hereby certify that I have prepared this application and that the work will be- done In :accordancel <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 CALVOR OR GROUT INSRECTION PR OR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED " <br /> TITLE: :aE DATE: <br /> D P OT P1 AN ON REVERSE E <br /> PHASE I OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY C..• /3, DATE 9f <br /> ADDITIONAL °COMMENTS: i k <br /> PHASE Ii GROUT 'INSPECTION PHASE III ' FINAL INSPECTION <br /> INSPECTION BY DATE <br /> INSPECTION BY DATE M <br /> EN 14 26° Rev. 9/78 0170 0M <br />