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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 41 <br /> r <br /> Telephone: {209} 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (complete In Triplicate4-1 <br /> d <br /> (- •l <br /> Application is hereby made to the San Joaquin Local Health District for a permit to' construct <br /> and/or ,i.nstall 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 CITY' WN <br /> Owner's Name Phone'' <br /> Address Cityi . <br /> Contractor's Name icense# a Phone �. <br /> IS CERTIFICATE OF WORKMAN S C01MPENSA Otd INSURAINCE ON FILE WITH 'SJLHD? .. __ YES _ 0 <br /> TYPE OF WORK (Check) :, NEW WELL M DEEPEN ❑� RECONDITION ® DESTRUCTION O . .. _. <br /> ' WELL CHLORINATION D WELL ABANDONMENT 0 OTHERF-J <br /> PUMP INSTALLATION M PUMP REPAIR PUMP REPLACEMENT ❑ \ <br /> DISTANCE TO NEAREST: SEPTIC; TANK SEWER LINES, ..' i <br /> �` PIT PRIVY <br /> SEWAGE, DISPOSAL FIELD CESSP QL/SEEPAGE PIT OTHER V <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL V <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 Grave-1 Pack Depth of Grout Sea <br /> Cathodic Protection Rotary T <br /> Disposal Other y " Other <br /> of Grout t <br /> her Information i <br /> e - -Geophysical ' Surface Sear Insta . ed b <br /> RUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: - v... ]State Work Done } <br /> PUMP REPAIR: JAState Work Done <br /> DESTRUCTION OF WELL: --_-We]TlADiameter __ <br /> . Describe Material- and - rocs ure Approximate Depth <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 1 <br /> laws of California." <br /> f' WILL CALL FOR A- GROUT INSPECT N,PRI R -0- ROUT NG AND "A'FINAL' INSPECTION. <br /> SIGNED +� DATE: <br /> PL NQN REVERSE SIDE <br />)HASE I OR PAR MENT USE ONLY 7. <br /> APPLICATION ACCEPTED BY <br />%DDITIONAL COMMENTS: ©ATE v� C <br /> M PHASE Ii GROUT INSPECTION PHASE II FINAL INSPECTION ' <br /> NSPE,CTION BY DATE _ INSPECTION BY <br /> 14' <br /> DATE <br />:H 26 Rev. 9/78 .ten �,. <br />