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SAN JOAQUIN LOCAL HEALTH DISTRICT Lem No. <br /> �• 1fi01 E. Hazelton Ave: , Stockton, CA 95205 <br /> &-L- <br /> tog USE: Telephone: (209) 466-6781 <br />� ssued3-�? -'7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (complete In Triplicate) <br /> Joaquin Local Application is hereby made to the San Health District for a permit to construct <br /> licatian ismadein compliance with San <br /> and/or in the work herein described. This app <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Joaquin <br /> District. CITY/TOWN <br /> EXACT STREET ADDRESS <br /> r Phone <br /> Owner's Name - <br /> r 1 <br /> AddressCity <br /> _ License# ' �� Phone <br /> Contractor's Name <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION d <br /> WELL CHLORINATION E3 WELL ABANDONMENT a OTHER <br /> PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT C1 <br /> DISTANCE: TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSr AL MELD CESSPOOLSEEPAGEpU—�BLIC DOMESTICR EL <br /> PROPERTY LINE - PRIVATE—DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> dustrial Cable Tool Dia. of <br /> XnWe 1 Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/private <br /> Domestic/publicDriven 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 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _. i . ,i" . _,:r ,# "Pr H.P. <br /> PUMP REP NT:: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 PTo—cedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordan <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <br /> Health District. Nome 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 F R A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED _. - r TITLE: DATE: <br /> _ rt. DR ON'REVERS SIDE <br /> PHASE .I OR DEPARTMENT A <br /> DATE <br /> 4 <br /> USE ONLY _ <br /> � - <br /> PPLICATION ACCEPTED BY <br /> ADDITIONAL .COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Q17R __2M <br /> FH 14 26 Rev. 9/78 <br />