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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE; 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.� �i� <br /> Telephone: (209) 466-6781 <br /> P_ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /�/ Wig' <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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local 'Health <br /> District. <br /> EXACT STREET ADDRESS �,�v CITY/TOWN <br /> Owner's Name Phone <br /> Address City rY <br /> Contractor's Name _ Li cense Phone�_�f <br /> IS CERTIFICATE OF WORKIMAN'S COMIPENSATION INSURANCE ON FILE WITH SJLHD? YES NO. <br /> TYPE OF WORK (Check) : NEW WELL Nf DEEPEN 0 RECONDITION [n DESTRUCTION( <br /> WELL CHLORINATION WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION PUMP REPAIR 0 PUMP REPLACEMENT E] AZ <br /> � <br /> DISTANCE TO NEAREST: SEPTIC TAN � SEWER LINES / � <br /> ��. PIT PRIVY <br /> SEWAGE DISPP SIELD CESSP L/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable 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 4 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor ' —`---� <br /> Type of Pump- - H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mateffal and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> Kith 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 dA - <br /> laws California. <br /> I WILL ALL OR GRO INSPECT N PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ' TITLE: DATE: 7 <br /> DVW PLOT PLAIN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br />'HASE I <br /> UPPLICATION ACCEPTED BY &A DATE <br /> kDDITIONAL COMMENTS: <br /> PHASE II GROUT—INSPEC- TION* v PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE • �-_zp'- �� INSPECTION 8Y DATE �J �-,� <br />:H 14 26 Rev. 9/78 <br /> 9/78 2M <br />