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• �" SAN JOAQUIN ..LOCAL HEALTH DISI-RIC-l' <br /> FORFFICE USE: 1601 E. Hazelton Ave. , Stockton, GA 95205 Permit No. <br /> Telephone: (209) . 4166-6781 <br />-- — APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires l 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 <br /> and/or install the work herein described. This application is made in compliance with San <br /> �Ioaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local :Health <br /> C,iStrct. <br /> EXACT STREET ADDRESS F �� I ^ r T CITY/TOWN. i <br /> Phone <br /> Owner's Name <br /> Address City } <br /> Contractor's Name Erb _ 12y i �nCj CL). Licensee Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA*aCE ON FILE WITH SJLHD? YES 1l r10 <br /> TYPE OF WORK (Check) : NEW WELL CEI,- DEEPEN ❑ RECONDITION-C3 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT p OTHER ❑ - <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY max' <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 Well Excavation <br /> t,- Domestic/private �Dril1ed Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing C2. <br /> Irrigation _ Gravel Pack Depth of Grout Seal f <br /> Cathodic Protection __jz Rotary Type of Grout ��1 <br /> Disposal Other a Other Information <br /> Seal Installed by: f <br /> Geophysical Surface e <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H• <br />[ PUMP REPLACEMENT: [] 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. <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED _)/Z i I ) 1 �' PI�IU E: l0, . DATE: <br /> (DRAW PLOT PLN REVERSE SIDE <br /> FO DEP IR USE ONLY <br /> PHASE I <br /> ,APPLICATION ACCEPTED BY []ATE ? <br /> tADDITIONAL COMMENTS: <br /> P E II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY r DATE BY DATE <br /> �._ 1 A ZM <br />