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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 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 ) t <br /> ('Complete In 'Triplicate) x <br /> Application is hereby made to the San Joaquin—Loc—al— Health District for a permit to construct t <br /> . and/or install. the work herein described. This application is made incompliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and' Regulations -of the San Joaquin Local Health <br /> District. <br /> EXACT ,STREET ADDRESS rCITY/TOWNs <br /> '. ti <br /> � � � <br /> ' :A.CD <br /> Owners Name <br /> Phone <br /> Address. 0 . City. <br /> Contractor's Name o License 2 D Phone <br /> IS CERTIFICATE OF WORKMAN'S C01;PENSATION INSURA"•SCE ON FILE 'WITH-SJLHD? YES NO <br /> TYPE OF WORK {Check)= 'NEW WELL 0 DEEPEN ❑ RECONDITION C3 DESTRUCTIONO <br /> WELL CHLORINATION Q . WELL' ABANDONMENT 0 OTHER � <br /> RUMP INSTALLATION <br /> - CM.. PUMP REPAIR❑`- PUMP REPLACEMENT [� <br /> i E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER- LINES lirP1T PRIVY <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PI OTHER <br /> C PROPERTY LINE - PRIVATE D MESTIC WELL PUBL C DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL., 1. ` ' CONSTRUCTION SPECIFICATIONS <br /> Industrial ` °_, Cable Tool Dia. f' Well Excavation <br /> Domestic/private '' Drilled Dia. of-WelI Casing <br /> --�omestic/public ' Driven Gauge of Casing <br /> —Irrigation Gravel Pack Depth of Grout Sea <br /> —Cathodic Protection Rotary Type `of. Grout <br /> Disposal Other Other InformatTon <br /> ,____`Geophysical Surface Seal Installed by: <br /> 'PUMP INSTALLATIpN_:—,Contractor <br /> Type of Pump O H.P. <br /> F <br /> ,PUMP REPLACEMENT " 'y'Q State Work Done ' <br /> ,PUMP REPAIR: (]State Work D <br /> - one.. .., . . - . <br />�011TRUCTION OF WELL l D N tl'Wel . <br /> t,,T.A proximate -Depth 6 G / <br /> Describe Materia ..and Proce ur <br /> 1 hereby"ce.rti fy�that I\have prepared�t. i-s �a-ppl i cati on and ;that the work will be donee i�n accordant <br /> with San- Joaquin County Ord inances•,. State Laws , and Rules and Regulations of-the Sane Joaquin Local. <br /> Health District. Home�ow�er`& 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. " x <br /> I WILL CALL F A GROUT I PECTION PRIOR TO GROUTING .AND A FI.-NU INSPECTION. <br /> SIGNED TITLE: DATE: <br /> D W P TL N ON. REVERSE S DE) <br /> PHA- R DEPARTMENT .USE ONLY _ <br /> APPLICATION ACCEPTED BY_, DATE G /� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III -FINAL INSPECTIO <br /> INSPECTION SY DATE INSPECTION BY DATE " �7�77 <br /> Elf 14 26 Rev, 9/78 9/78 2Ni <br />