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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Permit Na. - <br /> FORAOFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 - <br /> 'Telephone: (209) 466-6781 Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit .Ex fires 1 Year From Date Issued ; <br /> Complete In .Triplicate <br /> Application is hereby made to the San Joaquin focal 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 /> wi strict.. t <br /> EXACTSTREETADDRESS W c c� CITY/TOWN <br /> Phone <br /> Owner's Name r <br /> Pity <br /> Address <br /> Contractor' s Name r License#��� Phone <br /> I5 CERTIFICATE OF WORKMAN'S CO?"PENSATIO"! Ii1SURAINCE ON FILE WITH SJLHD? YES �^ id0____^� <br /> TYPE OF WORK (Check) : NEW WELL b DEEPEN ❑ RECONDITION DESTRUCTION M <br /> WELL CHLORINATION E1 WELL ABANDONMENT 0 OTHER -4� ~� <br /> PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENTT� <br /> v ' <br />( DISTANCE TO NEAREST: SEPTIC TPOSAL FIELDER LINECESSPOOL/SEEPAGEPRIVY <br /> PIT OTHE+ --* <br /> SEWAGE DISPOSAL -- %i <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 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing — ' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> —Disposal <br /> Othe,r Other Information , r' <br /> Geophysical Surface Seal Installed b <br /> [ PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: []State Work Done <br /> I PUMP REPAIR: QState Work Done _- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Proce ure <br /> lI hereby certify that I have prepared this application and that the work will be done in accordanc <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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: - <br /> DR W PL T PL N ON REVERS ID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE���� <br /> IAPPLICATION ACCEPTED BY - <br /> ADDITIONAL COMMENTS : PHASE II FINA INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �� DATE <br /> 78 <br />