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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 7DateIssued_S <br /> No. <br /> E Telephone:p (209') 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ,Zr <br /> (complete In Triplicate) <br /> Application is hereby madeito the San Joaquin Local Health District for a <br /> ermitand/or install the work herein described. - This application is made in compliancetwithnSanstruct <br /> Joaquin County Ordinance Noy' 1862 and the Rules and Regulations of- the San Joaquin 'Local Health <br /> District. <br /> EXACT STREET ADDRESS <br /> Owner's Name _ <br /> CITY/TOWN <br /> Phone <br />' Address '.' ..- � °r=-� <br /> City -3�VA/� <br /> Contractor's Name <br /> 1icensePhone <br /> IS CERTIFICATE -OF WO 11AN'S COMPENSATION INSURANCE ON#FILE WITH SJLHD? <br /> YES ✓ 0 .. <br /> ,TYPE OF WORK (Check) : NEW WELL DEEPEN Q ` RECONDITION ® DESTRUCTION[� r.. <br /> WELL CHLORINATION] WELL ABANDONMENT ® OTHER E3 I <br /> PUMP INSTALLATION M PUMP REPAIR 0 -PUMP REPLACEMENT [ j ~ <br /> DISTANCE TO-NEAREST:- . .SEP.TIC TANK ,o5­S.EW.ER--LINES1d, —P I T -PR-i-VY� <br /> � �7y V EWAGE DISP SALt IELD t CESSPOOL/SEEPAGE PI�S ` OTHER �—T <br /> PROPERTY LIN PRIVA"E DOMESTIC WELIJVO-0—e PUBLIC DOMESTIC WEL <br /> INTENDED USE TYPE OF-WELL. CONSTRUCTION SPECIFICATIONS <br /> Industrial - -CableTool Dia. of Wali Excavation r <br /> �flomestic/private Drilled Dia. of Weil Casing <br /> .,_„`Domestic/public <br /> ________Irrigation -�^- Dri ven. _ ..� --Gauge of Casing- - � � <br /> Gravel .Pack 4 Depth of Grout Sea <br /> Cathodic Protection Rotary - Type of Gr1.out _ s <br /> sposal Other Other Information <br /> _ _,�Geophys ca,l ; :', ; <br /> A Surface Seal Insta e <br /> PUMP INSTALLATION: Contractor <br /> A Type-.o f~R <br /> PUMP' REPLACEMENT; J <br /> a State Work Done <br /> PUMP REPAIR: OState Work Done R <br />_DESTRUCTION OF WELL: Well ,Diametera <br /> -Approximate Depth <br />_. Describe -Material and Procedure <br /> I hereby certify that I have prepared -this application and that the work will be done in_.acor- x <br /> with .San.,J.oaqui-n-.County-Ordi-nanees-,� State_Laws , -and.--Rules--and--Regu1-ations of the-San JoaquinLocal, <br /> Health District. dome owner or licensed agent's signature certifies the following: <br /> "I certify that i-n the performance of the work for -which= this; permit- is - issued, I shall <br /> not employ any person in such manner as 'ta`�become 's'Ubject to,Workman's' Compensation <br /> laws of-.California-. " <br /> I WILL C FOR ROUT I PECTION PRIOR TO GROUTING AN A FI L INSP CTION. <br /> SIGNED i I d TITLE: . - - <br /> D W PL T L N ON REVERSE S D DATE: £ <br />'HASE I R DE RTMENT USE ONLY <br /> PP�LICATION ACCEPTED BY <br /> kODITIONAL COMMENTS: fI DATE Z2-14� <br /> P I GROUT INSPECTION <br /> NSPECTION BY DATE .��')47 PHASE III 'FINAL INSPECTION" <br />'H 14 26 Rev. 9/78 INSPECTION BY DATE <br /> 9/7ft 991 <br />