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SAN JOAQUIN LOCAL HEALTH 'DISTRICT <br /> r1J__,FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION- FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7� <br /> This Permit Expires 1' Year From Date Issued <br /> Ir . . Complete In Triplicate <br />' Application is. hereby made toithe San Joaquin Local Health District for a permit to construct <br /> and/or. ,install::the work- herein described. This application is made incompliance with .San <br /> ,oanuin County Ordinance No//. {1862 and ti Rules and Regulationsrof the San Joaquin Local Health <br /> J i 5 t r 1 C t. �lJl1a/�•' C4.S.7`F�fs>✓ �� ,i <br /> EXACT STREET ADDRESS �?- a. CITY/TOWN n� <br /> Owner's Name �' Phone <br /> Address. --�! <br /> ��¢ ,Vd> City . <br /> Contractor's Name <br /> License# Phone <br /> Sl <br /> IS CERTIFICATE OF WORKMAN'S COMP NSATION INSURA"•SCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) NEW WELL L DEEPEN 041 ' RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER 0 � <br /> PUMP INSTALLATION ❑ PUMP REPAIR® PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 /> Domestic/private F--Drilled Dia. of: Well Casing <br /> Domestic/public 1.1 Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection 11, Rotary Type of Grout w <br /> -Disposal - " `-i! Other Other Information <br /> Geophysical Surface Seal Insta led b <br /> PUMP INSTALLATION: Contractor �Iyg � /� <br /> Type ofPump , r -- H.P. �-- <br /> PUMP REPLACEMENT: 3 Stal Work Done <br /> PUMP REPAIR: ! r <br /> Stat+ Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe MateriaT an& 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. " 11 ` <br /> I WILL CALL FORA GROUT INSPE T N TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE TITLE: d DATE: <br /> D W PLOT P , N ON REVERSE SILE1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY -, DATE b7 <br /> ADDITIONAL COMMENTS : �d,?- <br /> PHASE II GROUT INSPECTION PHASE I iNAL INSPECTION <br /> INSPECTION BY DAVE INSPECTION BY DATE <br />=H 1426 Rev. 12=77 1 P7 9V a <br />