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SAN JOAQUIN LOCAL 1,711EALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave.:; Stockton, CA 95205 Permit No. <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 and Regulations of -the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS <br /> le". CI'TY/TOWN <br /> Owner's Name .Phone <br /> Address City. <br /> Contractor's Name License# Picone <br /> JA S _ k� 10 <br /> IS CERTIFICATE OF WOR VAN' S' COMirENSATION INS ANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Z DEEPEN ❑ RECONDITION [2 DESTRUCTION❑ <br /> j WELL CHLORINATION ❑ WELL ABANDONMENTv <br /> 0 ,OTHER( <br /> PUMP INSTALLATION � <br /> M PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKsp 1.} SEWER LINESZ PIT PRIVY --- <br /> f SEWAGE DISPOSALIFIELDSv CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINP'O(PRIVATE D MESTIC WELD PUBLIi� DOMESTIC WELL -- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable Tool Dia-, of Well Excavation 2y <br /> Domes-tic/private - Drilled Da a. -of. Well Casin <br /> Domestic/public Driven g - <br /> Irri an on Gauge of Casing <br /> - g Gravel Pack Depth of Grout Seal Y <br /> _`Cathodic Protection 1 Rotary Type of Grout <br /> Disposal Otherr,. Other Information <br /> _Geophysical l/ ` Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> sa <br /> PUMP REPLACEMENT: 17 State Work Done -- <br /> � PUMP REPAIR: - . <br /> ❑State-Work Done <br /> DESTRUCTION OF WELL: Well '`Diameter <br /> j Describe Materia an Procedure Approximate Depth <br /> { I hereby certify that 'I have prepared this application and that the work will be de <br /> in <br /> with San Joaquin County Ordinances ;'State Laws , and Rules and Regulations of the San JoaquinoLocale <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 0 I P CTION PRIOR TOi_GROIlTING AND A`FINAL INSPECTION. <br /> .SIGNED <br /> -TITLE: DATE: <br /> D L L VON REV SI <br /> PHASE -I F R DEP RTMEN7 USE ONLY <br /> APPLIC/1TION ACCEPTED BY <br /> ADDITIONAL COMMENTS : DATE p <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE PHASE IIIFINAL INSPECTION, <br /> INSPECTION B��/ DATE <br /> ,EH 14 26 Rev. 9/78 � �� �� <br />