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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. -A-Ul' <br /> Telephone: (209) 466-678]. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued�1 <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- Regulatio s of the San Joaquin Local Health <br /> District. l <br /> EXACT STREET (O' /��iyt,� �- � -� <br /> " CITY/TOWN <br /> Owner's NamqLg�� CJT�, � Phone�� <br /> Address <br /> City , <br /> Contractor's Name =� Licens4 �3J� .phone <br /> F <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE' WITH-SJLHD? YES, ✓ 0- <br /> TYPE OF WORK (Check) : NEW WELL 0 --DEEPEN 0 RECONDITION <br /> WELL CHLORINATION D WELL ABANDON�MENT� DESTRUCTION <br /> N[) <br /> PUMP INSTALLATION M PUMP REPAIR Cg;,-- PUMP- REPLACEMENT [J <br /> 6� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIS OTHER � . <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL r' <br /> INTENDED USE'' TYPE-OF.WELL_. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool'' Dia. of Wei Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> /Domestic/public- Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sean <br /> Cathodic Protection - 1. <br /> Disposal � t. y Type of Grout <br /> p Other Other Information <br /> Geophysical Surface Seal Insta ed <br /> BUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Sta <br /> Q ate Work Done <br /> PUMP REPAIR: ;. Fi <br /> - �ate Work Don <br /> DESTRUCTION OF WELL: Well Diameter Approximate Dept <br /> Describe' Mate'rlal and ProEe ure <br /> k hereby "'certify that I have prepared this application and4that the work will be done in accordance <br /> w,,ith San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local <br /> Health-�Dis.trict 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 /> ' s not employ any person in such manner as to become subject to Workman's Compensation <br /> ° laws of California. " <br /> 1T WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> K.STGNED TITLE: <br /> DATE: �-JI <br /> DR W PLT L ON REVERS SIDE <br /> 4PHASE I <br /> F R D P RT ENT E ONLY <br /> PPS LICATION�ACCEPTED 8Yi4 <br /> DATE__aL <br /> ADDITIONAL -COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYo DATE-,' <br /> EH 14 26 Rev. 9/7a <br /> t <br />