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SAN JOAQUIN LOCAL,,HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton live: , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> ✓ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/ <br /> This Permit Expires IGYear 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 CITY/TOWN,sl�/U __- <br /> Owner's Name PhoneLt� { _ . <br /> Address vAVJ City Q o I <br /> Contractor's Name License# Phone '/ f <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATIO'll INSURAg•CE ON FILE WITH SJLHD? YES , .NOT <br /> ❑ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION CJ.. � <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR Q PUMP REPLACEMENT ❑ , <br /> DISTANCE TO NEAREST: SEPTIC TANK /CLD <br /> EWER LINES / PIT PRIVY <br /> SEWAGE DISPOSAL -- CES�L/SEEP�IGE PIT --- ' OTHER —.. <br /> PROPERTY LINfi/2,WRIVATE DOMESTIC WELL4 . PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE -OF WELL CONSTRUCTION SPECIFICATIONS_ <br /> Industrial __kCable Tool Dia: of Well Excavation 0 <br /> Domestic/private Drilled Dia. of Well Casing ►, <br /> Domestic/public Driven Gauge of Casinglrj <br /> Irrigation Gravel Pack _ Depth of Grout Seal UJ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ,� a , <br /> Geophysical - Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type- 'of Pump _ H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: Q State Work Done f <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 l <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 GROU I PEC PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> (DRAW PLT PLAN ON REVER SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,fy��— l DATE g P <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION RASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 10, <br />,EH ld9Fi "Pow 19_77 1 /78 2M <br />