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Co t!4 A SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CR 95205 Permit No. V-5 <br /> Telephone: (209) 466-6781 <br /> 01 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Exires .1 Year From Date Issued <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 S� GLJ a-o oe CITY/TOWN <br /> Owner's Name / Phone <br /> Address U City i <br /> Contractor's Name Li cense# /43 9ti- Phone 7$ <br /> i <br /> IS CERTIFICATE OF WORKMAN'S CO";PENSA 0"! IFJSURAIcICE ON FILE WITH SJLHD? YES NO j <br /> TYPE OF WORK (Check) : NEW WELLE] DEEPEN Q RECONDITION Q DESTRUCTION Q <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER Q <br /> PUMP INSTALLATION PUMP REPAIR Q PUMP REPLACEMENT C3 (n <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor. <br /> Type of Pump ,.S' e� ,F e, f P. �/✓ <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP -R: QState bark Done xzeg& <br /> DESTRUCTION OF WELL: Well Diameter Approximate -Denth:- _ <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 INSPECTIO -,R . R/ ROUT,ZN ND A FINAL INSPECTION. <br /> SIGNED DATE: <br /> /F ����N E ERSE SIDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I � 7'-` <br /> APPLICATION ACCEPTED BY DATE -11 �7f <br /> ADDITIONAL COMMENTS: <br /> PHASE I1 GROUT INSPECTION PHASE IIT FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ate---T DATE <br /> 1 /7R ZM <br />