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FFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. ,' Stocktor CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issuedy <br /> (CO.Inplete In Triplicate) <br />. Application is hereby made to the San Joaquin �Local Heal <br /> and/or install the work herein described. This application is mad <br /> Health District fora permit to construct <br /> Joaquin -County Ordinance No. 1862 and the Rules and' Regula't' of th <br /> e in compliance with San' <br /> District. a San Joaquin Local Health <br /> EXACT STREET D S �J�l <br /> Owner's Nam CITY/TOWN <br /> Address rf lPhone <br /> f .. <br /> Contractor's. Name L City <br /> License# �' �hone <br /> IS CERTIFICATE -OF WORKMAN'S COMPENSATION INSURANCE ON FILE W.ITFI S ? t�-- <br /> TYPE OF' WORk (Check) : NEW WELL L DEEPEN (] RE' <br /> COfVDIT JLH1. YES 0 <br /> WELL CHLORINATION ION Q ,a DESTRUCTION <br /> ED OTHER 0. <br /> PUMP INSTALLATION 0, PUMP REPAIRPUMP REPLACEMENT <br /> Q f <br /> DISTANCE TO NEAREST: - SEPTIC TANK <br /> SEWER LINES •..PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/cEEPRGE PTS` ;� ' • <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL______ PUBLIC DO EM SOTICRWEL <br /> m INTENDED 'OSE` TYPE OF.WELL., - <br /> ��,Industrial CONSTRUCTION SPECIFICATIONS.- <br /> � - <br /> Domestic/private _ able Tool Dia. of We 1 Excavation <br />`� —�--Vii Drilled Dia, of Well Casing <br />� Domestic/public t. Driven <br /> Irrigation A Gravel Pack Gauge-of Casing <br />--.Cathodic Protection k Rotary eptW of Grout Sea <br />,`;Disposal Other, r Type of Grout <br /> 6eophysica] --- Other. Information <br /> Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor <br /> Type of. 'Pu <br />'UMP REPLACEMENT: ' <br /> State Work Dong <br /> U�EP�AIR_:'* <br />►E57R CU TION OF WELL: Well Diameter. - --- =` -- � — - -- --. <br /> ' "Describe- Mate'd a and Procedure <br /> Approximate Depth <br /> hereby certify that I have prepared this application- and' th <br /> ith San Joaquin County Ordinances, State Laws , and Rules and Regulations of th <br /> ealth District;: Home owner or licensed agent's at the work will be done in accordance <br /> . "I certify that in the performance of the work for which this permit a San Joaquin 'L'ocal <br /> 9 s signature certifies the following: <br /> not employ any person in such manner as to become subject to orkman's Comped, I shall <br /> laws of California. s Compensation <br /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINRL INSPECTION. <br />'GNED <br /> A TITLE: / <br /> DR W PL T PL N ON REVER E SIDE DATE:----------- <br /> ASE i �' F R D P RTM NT USE ONLY <br /> PLI AT10N ACCEPTED BY <br /> D.ITIONAL COMMENTS: DATE G /3 7y <br /> .- PHASE II GRDUT INSPECTION <br />;PECTION ByDATE PHAS III FINAL INSPECTION <br /> 14 26 Rev. 9/78 INSPECTION BY <br /> _ � DATE - 13-1 <br />