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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton .Ave. , Stockton, CA 95205 Permit No. Dyzt2]E�r-1 <br /> Telephone: (209) 466-6781 <br /> � �' � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued; 1-- <br /> This Permit Expires 1 Year From Date Issued <br /> r Complete In Triplicate ' <br /> Application _is hereby made to the San Joaquin Local Health District for- a� perm t to construct <br /> and/or install the work herein described. This application -is made in compliance with San <br /> uoaQuin County Ordinance No. 1862 and the -Rules and Regulations -of- the San Joaquin Local Health <br /> Distr'ct. <br /> EXACT STREET AD SS CITY/TOWN <br /> eo <br /> Owner' s Name Phone S- <br /> Address City. . .. . <br /> Contractor's Name License#:S3 W2 L Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO11 INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION [] DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVYOTHER <br /> SEWAGE DISPOSAL FIELD • PIT.CESSPOOL/SEEPA E \ <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 ,I Drilled Dia. of Well Casing <br /> Domestic/public !f Driven Gauge of Casing. <br /> Irrigation TGravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal 1 Other Other Information <br /> Geophysical it Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor r <br /> Type 'of Pump H.P. <br /> PUMP REPLACEMENT: ❑ Sta'te Work Do7e <br /> PUMP' REPAIR: ❑;State Work- Done <br /> DESTRUCTION OF WELL: Wel1 ,Di�ameter Approximate Depth <br /> Describe Materia and 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 th.e 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 R A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> (DRAW PLOT PLAN- ON REVERSE SIDE <br /> FOR DEPARTMENT- USE ONLY <br /> PHASE I <br />'APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : t <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY. DATE INSPECTION BY - DATE {. <br />.CLI 1 A9G ❑.... 1 77 <br />