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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rICE USE: ✓ 1601 E. Hazelton Ave. _,- Stockton, CA 95205 Permit No. b <br /> Telephone: (209) 466-6781 r' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �— b---7_ <br /> � - This Permit Ex ires I Year From Date Issued <br /> J 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 /> ,'oaqui n County Ordinance No. 1862 and the Rules and. Regulations of the San Joaquin Local Health <br /> Distract. N_. - <br /> EXACT STREET ADDRESS S CITY/TOWN <br /> Owner's Name—,.-/ phone <br /> Address City <br /> Contractor' s Name 'c I ense#.2&L3 Phone <br /> IS CERTrFICATE OF WORKMAN'S COMPENSAT ON INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ W <br /> PUMP INSTALLATION Cl PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY -C <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATAOW <br /> Industrial Cable Tool Dia. of Well Excavation <br /> omestic/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 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 w is s permit is issued, I shall <br /> not employ any person in such manner as to b come subject o Wor man 's Compensation <br /> laws of Ca fornia." <br /> I WILL CALL IdRIA GROUT INSPE IO PRIOR TO GRDUTI AND A FI AL I 5P i0 . <br /> SIGNED TITLE: DATE:6��hlr� <br /> "�DPLOT TLTN ON R R ce E ID <br /> FOR DEPARTMEVTeE <br /> PHASE I ONLY <br /> APPLICATION ACCEPTED BY J DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE 11 GROUT INSPECTION PHASE III FIlAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE .,, <br /> EH 1426 Rev. 12-77 _ 1 /7 2M <br />