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~----� AN JOAQUIN LOCAL HEALTH DISTR <br /> FFICE USE: 160 E. Hazelton Avg. , Stockton, CA 95205 Permit No. <br /> 0 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued < -,D <br /> (Complete In Triplicate) <br /> 1plication is hereby made to the San Joaquin Local Health Distirict for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> ,.-'aquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> strict. <br /> C:1," <br /> L-",,,CT STREET ADDRESS <br /> CITY �'�OWN <br /> ner' s Name . �/�ietact �r � w....... <br /> cdress Phone- <br /> city , r <br /> City <br /> -�Itractor' s dames License#, Phone F� <br /> CERTIFICATE OF 140rK"IAN'S COQ PENSATIOtf TINSURA'7IC ON FILE WITH SJLHO? YES ^ NO <br /> 'E OF WORK (Check) : NEW WELLEM DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 C <br /> - PUMP INSTALLATION ❑ PUMP REPAIR❑ PU?,#P REPLACEMENT Q -� <br /> TANCE TO NEAREST: SEPTIC TANK, tai SEWER LINES - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD� CESSPOOL/SEERAGE PIT r-�OTHER <br /> PROPERTY LINE/Q• PRIVA DODO ESTIC WELLS,�22.-f- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> WSIndustrial Cable Tool Dia o'r Wd —11 Excavation <br /> I <br /> omestic/private Drilled Dia. of Wel '1 CasioDomesti c/publ i c <br /> �I rri gati on Driven Gauge of L:as i =-u „� <br /> Gravel Pack Depth of Grout�sea] <br /> Cathodic Protection ^Rotary Type of Grout <br /> Disposal Other <--- "•`��` <br /> eophysi cal Other Information /7-4icli r . <br /> Surface Seal Installed by, <br /> INSTALLATION: Contractor <br /> . Type of Pump H.P. <br /> 1MP REPLACEMENT: (State Work Done <br /> REPAIR: ❑State Work Done <br /> :STRUCTION OF WELL: Well Diameter <br /> Describe Materia and Procedure Approximate Depth <br /> hereby certify that I have prepared this application and that the work will be done in accordant <br /> San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin 'Local- <br /> th Districts 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 /> Lonot employ any person in 'such manner as to become subject to Workman's Compensation <br /> llaws of California. " <br /> �-• L CALL FOR,.'A G UT ,I SP <br /> ECTION PRIOR TO GROUTING AND A FINAL INSPECTION. di <br /> TITLE: k DATE: - e- <br /> DR W PL T PL N ON REVERSE SIDE <br /> - IFO DE ARTMENT SE ONLY <br /> CLITION ACCEPTED BY <br /> IONCOMMENTS: DATE S <br /> PHASE II GROUT INSPECTION <br /> CTT BY DATE PHASE III FINAL INSPECTION <br /> 426 Rev. 9/7$ *„_{Np ION 8Y DATE i, <br />