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SAN JOAQUIN LOCAL HEALTH DIST"ICT <br /> -_EPL FFICE USE: _ J1 E. Hazelton Ave. , Stockton, 95205 Permit No.7�-iS9 FS <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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 a d Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADTRESS_ ,` "'" CITY/TOWN <br /> Owner's Name _ � � Phone 6 f- �, ,x,7'7 <br /> Address City , <br /> Contractor' s Name a ��� ��c. - � Li cense#/ Phone <br /> IS CERTIFICATE OF WORKMAN'S CTIPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL[1 DEEPEN p RECONDITION ❑ DESTRUCTIONF1 ~ <br /> WELL CHLORINATION 0 WELL ABANDONMENT d OTHER ❑ � <br /> PUMP INSTALLATION a PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK! SEWER LINES Z av ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPbOL/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 lo " <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection _Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor 49 zzzil <br /> Type of Pump ,c �G H p. <br /> _ i <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 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 CAL OR A GROUT INSPECTION PR OR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED— � � ���� Z TITLE: DATE: <br /> DR W PLT L N ON REVERSE -7IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY L : J3DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> I'ISPFCT?ON R Y nATr- <br /> 7NIqDFl`TTfiN! ^V �nTr <br />