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SA" IOAQUIN LOCAL HEALTH DISTRICT <br /> IM FFI USF 1601 E. ielto6 Ave. , Stockton, CA 95 Permit No. 7 9- /d / <br /> J Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL' CONSTRUCTION OR 'PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local-'Health District for a permit to construct o <br /> and/or install the work herein described. . This..application is made in compliance with San 4- <br /> 2oanuin County :Ordinance No. 1862 and th Rules and Regulations of the San Joaquin Local/ Health C, <br />)istr+ct. i . <br />:XACT STREET ADDRESS ��� O�Q/Lc��lP� �i� > CITY/TOWN <br />)wner's Name Phone <br /> address ). City f <br />.ontractor's Name License# • lj Phone <br /> IS CERTIFICATE OF WORKMAN'S C iPENSATION INSURA!ICE ON FILE WITH SJLHD? YES NO <br /> rYPE OF WORK (Check) : NEW WELL4R-�—DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br />)ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Irb <br /> SEWAGE DISP SHIELD CESSPOOL/SEEPAGEI' T OTHER <br /> PROPERTY LIN -. PRIVATE DOMESTIC' WELL PUBLIC DOMESTIC WELL �1 <br /> INTENDED USE TYPE' OF WELL CONSTRUCTION SPECIFIC TIONS <br /> Industrial' ; Ce�Too1 Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing_ s <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation = Gravel. Pack Depth of Grout Sea <br /> Cathodic Protection Mary Type of Grout I • <br /> Disposal t Qther Other Information <br /> Geophysical Surface Seal Installed b <br /> DUMP INSTALLATION: Contractor <br /> Type of Pump H • <br />*UMP REPLACEMENT: ❑State .Work Done <br />*)UMP REPAIR: O State Work Done <br />)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe MatleriaT and Procedure, <br /> R 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 /> iealth District. Home owner or licensed agent' s signature certifies the following: <br /> "I cer t in the performance of the work for which this permit is issued, I shall <br /> n employ an per n such manner s to become subject to Workman's Compensation <br /> aws of Cali ornia." 1. <br /> WIL ALL FO A GROU I T IDR TO GROUTING'A A FIN INSPECTION. <br />;IGNED [ Or TITLE DATE: <br /> zz (DRAW PLOT PLVN ON REVME SIDE) <br /> FOR `DEP RTMENT<JSE ONLY <br />"RASE I <br /> aPPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III fINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE <br />