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SAN JOAQUIN LOCAL HEALTH DISTRICT -- ---.��.- <br /> Fi 'E USE: ` f601 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 Expires 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 /> ,'oaQui n County Ordinance No. 1862 -and the Rules and Regulations of the San Joaq in Local Health <br /> £ (�TRE:ET ADDRES Se-ft A4OL CITY/ <br /> TOWN <br /> CITY <br /> Owner' s Name Phone <br /> Address o a City <br /> Contractor 's Name „ License# l 2724"Phone 2�6i 76 76 <br /> IS CERTIFICATE OF WORKMAN- r,1VPE ATIO"1 INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE <br /> OTYPE OF WORK (Check) : NEW WELL 0 DEEPEN Q RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT E3 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 JN <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 /> c Irrigation Gravel Pack Depth of Grout Sea <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 H.P. s <br /> PUMP REPLACEMENT: C] State Work Done <br /> PUMP REPAIR: E]State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <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 CALL FOR A GROUT G_N­SK0IQN_P_R'JVR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: ,ODATE: <br /> W PLOT N ON REVERSE SIDE <br /> F�F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE-7- <br /> EH_ 1426 _ Rev. 12-77 _ _ 1./78 <br />