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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> =OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. z-(ZI { <br /> Telephoner (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (tromplete . 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 CITY/TOWN_ C ' <br /> Owner's Name Phone <br /> Address City , <br /> Contractor's Name License# 3 Phone <br /> I5 CERTIFICATE OF WORK�1Ats'S CO"iPENSATIOFI I�ISURA"!CE QN FILE WITH SJLHD?. YES 0 <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN O RECONDITION Q DESTRUCTION[1 <br /> WELL CHLORINATION 0 WELL ABANDONMEN34n OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP-64L/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 Excavation <br /> Domestic/private Drilled Dia. of Well Casing- <br /> Domestic/public Driven Gauge of Casing <br /> _Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> _Geophysical Surface Seal Insta ed y. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP :REPLACEMENT: Q S ate Work Done <br /> PUMP REPAIR: State Work Done <br /> 1 <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with Sari 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." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED _ TITLE: DATE: �'f <br /> (DRAW PLOT PLAN ON REVERS SID <br /> PHASE I <br /> R DEP RTM NT USE ONLY <br /> PPT LICATION ACCEPTED BY "A <br /> DATE / <br /> 21771 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �1— <br />,EH 14 26 Rev. 9/78 -017Q 42M- <br />