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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR F ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.�72-aZ5 <br /> Telephone: (209) 466"6781.' <br /> 71 <br /> ` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date IssuedI. A9 <br /> (complete 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 /> EXACT STREET ADDRESS V CITY/TOWN OfB <br /> Owner's Name• �, , ,,.� Phone <br /> Address <br /> 1 z� C i ty , <br /> Contractor's NameL44,edal License# Phone %rr' <br /> IS CERTIFICATE OF WORKMAN'S CO" EN ATION INSURANCE ON FILE WITH SJLHD? YES 0" <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION [❑ DESTRUCTION❑ �-- <br /> WELL CHLORINATION WELL ABANDONMENT❑ OTHER 0 -C <br /> PUMP INSTALLATION PUMP REPAIRED PUMP REPLACEMENT ❑ N <br /> W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT 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 Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> )e' Domestic/public Driven Gauge of Casing <br /> x Irrigation Gravel Pack Depth .of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instar ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. . <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP R==: ( State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and 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." <br /> I WILL CALL FOR A GROUT INSPEC LOR 0 GRDUTING AND A FINAL INSPECTION. <br /> SIGNED ITLE: DATE: <br /> PLOF PLAN ON REVERSE ID <br /> DEP TMEN ON <br /> SE LY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DAT <br /> ADDITIONAL COMMENTS: pe <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE 41- 2-7- �V <br /> EH 14 26 Rev. 9/7 9/78 2M <br />