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SAN JOAQUIN LOCAL HEALTH DISTRICT a <br /> OFFICEFOR USE: 1601 E. Hazelton Ave. ,_:Stoc.kton.; CA 95205 Permit No 2�� . <br /> Telephone: (209) .466-6781 . i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued <br /> (Complete In Triplicate)' ; <br /> Application is hereby made to the San Joaquin Local- Heal'th District for a 'permit to construct , <br /> acrd/or install the work. herein described. This application ,is made in compliance with San <br /> Joaquin County' Ordinance No! 1862 and the Rules and Regulations .of the San 'Joaqui n Local Health - <br /> District. <br /> EXACT STREET ADDRESS ,� � � ` <br /> 'r CITY/TOWN IP Il�l7 <br /> Owner's Name' ' Phone 9 - <br /> Address— - City <br /> Contractor' s Name _-„ / -,S /aI ,( 1°�,� ' L cense# Phone 3 �T <br /> IS CERTIFICATE OF WORKIIA14-S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES O <br /> TYPE OF W6RK4(Check) : NEW WELL 0 DEEPEN 0 RECONDITION ®Y DESTRUCTION n <br /> WELLFCHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 _ � <br /> i PUMP `INSTALLATION 0 .PUMP REPAIR CI PUMP REPLACEMENT <br />' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER- <br /> f PROPERTY LINE - PRIVATE DO ESTIC WELL PUBLIC DOMESTIC WELL <br /> #- - INTENDED USE' TYPE OF -WELL.. CONSTRUCTION SPECIFICATIONS <br /> Industrial v Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled R Dia._ of. Well _-Casi.n..g.�- -�- <br /> r,- Domes-ti-c/0-ubl-icy'- D�^i'ven -- F —'Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Y Geophysical �� Surface Seal Instaed b : <br /> PUMP INSTALLATION: Contractor C` <br /> Typelof Pump H• <br /> 'PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Dane <br /> 5 DESTRUCTION OF WELL: Well Diameter f" . 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 accordar <br /> .( with San Joaquin County Ordinances ,. State Laws , and Rules and Regulations of the San Joaquin -Luca <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 R A GROUT NSPEC ION P IOR. TO GROUTING AND A FINAL INSPECTION. <br /> tSIGNED TITLE: , DATE: <br /> (DRAW PLOT PLAN ON REVERSE SIDE ' <br /> R DEPARTMENT USE ONLY <br /> '' PHASE I <br /> 1APPLICATION ACCEPTED 8Y DATEj4if7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III NAL INSPECTION <br /> INSPECTION BY DATE AIA INSPECTION BYE/ DATE <br /> EH 14 26 Rev. 9/78 - /78, <br />