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OWP <br /> SAN JOAQUI.N LOCAL HEALTH DISTRICT <br /> MROF -USE: 1601 E. Hazelton Ave.., Stockton, CA 95205 Permit No.7 9-6 . <br /> I Telephone: (209) 466-6781 .� <br /> ued <br /> APPLICATION FOR WELL CONSTRUCTION OR. PUMP PERMIT Date :Issr <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' witf San <br /> Joaquin 'County Ordinance No. 1862 and the Rules and .Regulations of the San Joaquin Local Health <br /> .District. 4 z <br /> EXACT STREET ADDRESS CITY/MOWN .' <br /> iOwner's Name Phone <br /> Address . Ci t y'_.:_:�. <br /> Contractor's Name w �� ��,,'� _ _ License# 29� Phone <br /> IS CERTIFICATE OF WORKMAN'S CO"IPENSATION INSURAINCE ON FILE WITH SJLHD? YES 0 ; <br /> _`TYPE OF WORK (Check) : NEW WELL M DEEPEN rJ - RECONDITION DESTRUCTION[] . <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Q- PUMP REPAIR 0 PUMP REPLACEMENT 0 <br /> PISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY s <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL_ -- PUBLIC. DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool . . Dia. of Wel Excavatl0n <br /> Domestic/private Drilled Dia. of Well Casing <br />µ$ Domestic/public Driven Gauge of Casing <br /> s Irrigation Gravel Pack Depth of Grout Sea ' <br /> Cathodic Protection Rotary ' --Type of Grout <br /> t Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> 'SUMP INSTA_LLAT_ION: Contractor 4 . <br /> Type of Pump <br /> PUMP REPLACEMENT: [ 2]State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 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.". w. �... <br /> I WILL CAL FOR A GROUT INSPKTJOPpOnTO GROUTING AND A`FINAL INSPECTION. <br /> SIGN ITLE: f DATE: <br /> HRKP ON REVERS SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br />, APPLICATION ACCEPTED BY &_21 DATE <br /> ADDITIONAL COMMENTS: . r <br /> PHASE II GROUT INSPECTION PHA E III FINAL INSPECTi <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> SEH 14 26 Rev. 9/78 - r M 9/78 2M <br />