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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE; 1601 E. Hazelton Ave.., .Stbckton, CA 95205 Permit No. <br /> Telephone: (209) 466--6781 <br /> S <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ,:-`_-�77' <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install. the work herein described. This application -is made in compliance with San , <br />.'oanuin. Cnunty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. . <br /> EXACT.. STREET ADDR CITY/TOWN,.S <br /> Owner' s Name <br /> Phone -- �� <br /> Address a <br /> -City f <br /> Contractor's Name �—. <br /> -r✓ Li cens �� Phone '�'� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE 0'�, . FILE WITH SJLHD? YES�� NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Lam-. WELL ABANDONMENT ❑ OTHER 0 � <br /> PUMP INSTALLATION 0 PUMP REPAIR Q.._ PUMP REPLACEMENT Q '� <br /> • b <br /> DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES PIT PRIVY <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 , F <br /> Disposal 'Other Other Informaf on <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: 25tate Work D� <br />)ESTRUCTION OF WELL: Well Diameter <br /> Dept <br /> Describe Materia and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance. <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 /> 4 <br />�IGN£D TITLE: . 2�, DATE: `f-d7S' <br /> DR W; PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />'HASE I <br /> iPPLICATION ACCEPTED BYt.. DATE s1zl2B <br /> kDDITIONAL COMMENTS: fir• . •• _ i <br /> PHASE fII .GROUT:�,INSPECTI,ON PHASE II FINAL INSPECT ON <br /> NSPECTION BY ''' T'�" ' ' DATE/_�' INSPECTION BY <br />