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I� SAN JOAQUIN.LOCAL HEALTH DISTRIC-I <br />r 1601 E. Hazelton Ave., Stockton, CA 95205 <br />Telephone: (209) 456-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br />This Permit Expires I Year From Date .Issued <br />.1 Complete in Triplicate <br />Permit No. <br />Date Issued 7 <br />Application -is hereby made to -the San Joaquin Local Health District for a,permit-to construct <br />and/o), i'nstalf the work herein described. This application is made in compliance with Sari <br />�'OdnU�n County C'rdinance ��o_� 1862 and the R les aril Regulati ns. f he S.an. Joaquin, Local Health <br />District. I� <br />E EXACT STREET �xAD�}RESS„ <br />;Owner's Nam <br />Addre�-s . <br />.Contractor's Name Licens <br />CITY <br />Phon <br />i ty <br />on <br />ITS CERTIFICATE OF WOUNAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br />TYPE OF WORK (Check)t NEW WELL L DEEPEN Q RECONDITION 0 DESTRUCTION ED �. <br />WELL CHLORINATIONWELL ABANDONMENT Q • OTHER 0 <br />PUMP INSTALLATION tj PUMP REPAIR 0 PUMP REPLACEMENT [I 9 <br />°DISTANCE TO NEAREST:I' SEPTIC TANK SEWER LINES PIT PRIVY <br />SEWAGE DISP S� AL FIELD CES9P00L/SEEPAGE PIT OTHER <br />R PROPERTY LINE -.PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br />INTENDED USE'. TYPE OF WELL 'CONSTRUCTION SPECIFICATIONS —� <br />Industrial Cabe Tool Dia. of Well Excavation <br />DomesticJprivate D 'll d <br />Domestic/public <br />Irrigation <br />Cathodic Protection <br />Disposal I <br />I a }a. o e Casing <br />Driven Gauge of Casing <br />Gravel Pack Depth of Grout Seal <br />Rotary Type of Grout <br />Other Other Information <br />Geophysical '. Surface Seal Installed by: <br />iPUMP INSTALLATION: Contractor <br />Type of Pump H.P. <br />'PUMP REPLACEMENT: State Work Done- ek <br />PUMP REPAIR: VState Work Donee-` <br />DESTRUCTION-OF'WELL.'' `-WellDiameter f - Approximate <br />Describe Material and Procedure <br />I hereby certify than I have prepared this application -and that the work will be done in accordar <br />with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Loci <br />Health District. Hdme owner or licensed agent's signature certifies the following: <br />"I certify that i.n the performance of t -he 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; Californias." <br />I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />!SIGNED, TITLE: DATE: <br />DRAW PLOT PLAN ON REVERSESI-DE) <br />II t UK ULNAK I MLN I U5L UNLY <br />PHASE I �� - t...:. '''' Vr. `f <br />APPLICATION ACCEPTED BY -. "': �.>''� r DATE <br />'ADDITIONAL COMMENTS'. <br />PHASE II GROUT'INSPECTION r*PHASE I -TNAL INSPECTION <br />INSPECTION BY DATE -- I14SPECTION BY_ <br />DATE <br />�u la2F �Qo„ 19_`7 7 x/78 2M <br />