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SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> PFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7P <br /> `Telephone: {2O9) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires l Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. - This application is made incompliance 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 7;j" CITY/TOWN.-7- <br /> Owner's <br /> ITY/TOWN Owner's Name5-7t,1 "' Phone C` <br /> Address zz- " City z— <br /> Contractor' s Name Licensees Phone - :F- <br /> I <br /> IS CERTIFICATE OF WORKMAN'S C0111PENSATION IIJSURAIICE ON FILE WITH SJLHD? YES NO <br /> i <br /> TYPE OF WORK (Check) : NEW WELL O DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT C1 OTHER [ \ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ ln1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY V <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS _ C <br /> Industrial Cable Tool Dia. of Well Excavation— <br /> Domestic/private Drilled Dia. of Well Casing 95n_ <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 /> t <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 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 RUT INSPEC ON PRIOR TO GROUTING AND A FINAL INSPECTION. <br />' SIGNED TITLE: DATE: <br /> DRAW PLOT PLAN ON REVERSE SfDE!15� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �6�, __ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN3PECTION PHASE III FLML INSPECTION <br /> INSPECTION BY DATE INSPECTION B � [a— DATE ,r— <br />