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SAN JOAQUIN LOCAL HEALTH DISTRICT_ <br /> FFI E USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permft 'No. _ <br /> ' Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued r? i <br /> (Eomplete 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 /> Joaquin -County Ordinance No.' 1862 and the Rules and' Regulations of the San Joaquin Local Health <br /> District. <br /> a <br /> EXACT STREET ADDRESS CITY/TOWN <br /> �j . <br /> Owner's Name _ J �22J Phone w <br /> Address L� Cit <br /> Contractor's Nam LSr' c License /Z hone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON. FILE WITH SJLHD? YES NO, <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN ❑ RECONDITION DESTRUCTION[ A <br /> WELL CHLORINATION 0 WELL ABANDONMENT C} OTHER rJ N <br /> PUMP INSTALLATION M­-'fUMP REPAIR[]• PUMP REPLACEMENT Q <br /> C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PI_ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC D MESTIC WELL <br /> INTENDED USE TYPE OF_WELL..., CONSTRUCTION SPECIFICATIONS <br /> } Industrial Cable Tool Dia, of Wel Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing .. <br /> Irrigation Gravel Pack Depth of Grout Sea. <br /> Cathodic Protection Rotary. Y Type of Grout - <br /> Disposal <br /> " 0 er Other Information <br /> Y <br /> hl-� Geophysical Surface Sea] Insta ed-! <br /> f <br /> PUMP. INSTALLATION: Contractor �"'��' <br /> Type of Pump H.P:' <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: Q State-Work Done <br /> DESTRUCTION OF WELL: Well Diameter ` <br /> Describe Materia an Procedure <br /> Approximate Depth <br /> 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 certifieSL-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 .Ca ifornia." , <br />. I WILL CALL F A GROUT INSPECT PRIG O GROUTING AND INAL INSPECTION. <br /> SIGNED �(� TITLE: c� DATE: /-z7- 7.2 <br /> R T L % REVERSE SIDE <br />'PHASE I R DEPARTMENT ASE ONLY <br /> APPLI AT10N ACCEPTED BY -tit DATE l <br />.ADDITIONAL" COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III 'FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE _-1q <br /> EH 14 26 Rev. 9/78 017sz 9 <br />