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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQR' OF�ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No• 79-3 a <br /> Telephone: (209) 466-6781 Ff <br /> APPLICATION FOR WELL CONSTRUCTION OR RUMP PERMIT Date Issued _ _7 :4 <br /> This Permit tx ires 1"Year From Date Issued <br /> Complete In Triplicate <br /> A <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 /> Joaquin County Ordinance .No. 1862 and the Rules and. Regulations of the San Joaquin Local, Health <br /> District. ' <br /> EXACT STREET ADDRESS �� CITY/TOWN <br /> Owner's Name Phone --o <br /> Address City C04 } <br /> Contractor' s Name d �- l Li cense#F;2?6d Phone 44V <br />'4 IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES 4---NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION[] e <br /> WELL CHLORINATION Q WELL ABANDONMENT OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT A <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD I CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC_ATIONS <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 Inst fled by: <br /> PUMP INSTALLATION: Contracto <br /> Type of Pump H.P. a? <br /> PUMP, REPLACEMENT: X State Work Done <br /> PUMP REPAIR: Q 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 accordanc <br /> , with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin,.Local <br /> tiHealth-•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." Lr� <br /> I WILL CALL FOR A GRMI INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DR W PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I y <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTIO <br /> ISPECTION BY DATE INSPECTION BY DATE <br />