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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> =.,QFFICE USE: 16D1 E. Hazelton Ave. , Stockton, CA 95205 Permit No. Lo <br /> Telephones (.209) 466-6781 <br /> APPLI-CAT ION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued-5_1-29 j <br /> (Cump-lete In Triplicate')__I <br /> Application is hereby made to, the San Joaquin Local Health District' <br /> for a permit to construct ' <br />_ ,and/or install, the work.: herei'n described. This application is made;fin:compliance with Sane <br /> Joaquin County Ordinance No. -.1862 and the Rules and Regulations -of the San Joaquin Local Health ' ". <br /> District. <br /> !EXACT STREET ADDRESS: ` CITY TOW <br /> ;Owner's Name s "Phone <br /> Address <br /> Ci ty, <br /> Contractor's Nam 1ALicense# _ Phone <br /> I5 CERTIFICATE OF WORKMAN'S 6"1NSATIOrJ INSURANCE ON FILE WITH SJLHD? -YES 0 <br /> s <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ � <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR O PUMP -REPLACEMENT E4., f <br /> 'i <br /> ?DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE: DISPOSAL FIELD CESSP L/SEE'P'AGE P�_ 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 /> t � Domestic/private Drilled' Dia.: .of Well Casing - s <br /> Domes't.ic%public Driven 4 Gauge of Casing ; <br /> Irrigation rGravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type-of-Grout <br /> - <br /> isposal Other Other Information <br /> s . GeophysicalSurface Seal Installed by: <br /> PUMP. INSTALLATION: Contra. <br /> ,tor <br /> r <br /> .Type of Pump '. _ H.P. <br /> PUMP REPLACEMENT: ER State Work Done__Ad <br /> PUMP REPAIR: O State Work Done p <br /> rs <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an ,Proce ure <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 Joaqui.-n -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 TMm <br /> laws 'of California. " <br /> I WILL CALL FOR A GROUT INSPECT N PR GROUTING AND A FINAL INSPECTION, <br /> SIGNE IITLE: DATE: <br /> YURAW-.PLOT PL ON REVERSE SIDE <br /> OR DEPAR____T USE ONLY <br /> PHASE I — <br /> APPLICATION ACCEPTED -BY DATE 111,z7 <br /> ADDITIONAL COMMENTS i <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY - DATE INSPECTION BY DATE <br /> EH 14 26 Rev. 9/78 <br />