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SAN JOAQUIN LOCAL HEALTH DISTRICT �� � � <br /> FOR OFFICE USE: -741501 E. Hazelton Ave. , Stockton, CA 95205 Permit No.9 <br /> Telephone: (209) 466-6781 / �j1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued / d <br /> Thus Permit Expires I. Year From Date Issued <br /> (`Complete n Tri p 1 i rate <br /> kpplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ind/or Install the work herein described. This application is rude in compliance with San <br /> 'oan � n County Ordinance—No. 1862 an the Rules and Regulations of the San Joaquin Local Health <br /> istrict• � <br /> _XACt *STREET ADDRESS f�U CITY/TOWN <br /> )wner's Name Phone <br /> 'address _R Ci ty <br /> :ontractor's Name z LicenseL3_ I Phone <br /> IS CERTIFICATE OF WOR0AN'S COMPENSATION, INSURAMCE OiN FILL WITH SJLHD? YES 'yC NO <br /> r <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN 0 RECONDITION DESTRUCTION[) <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIRCq PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP I�}L/SEEPAGE TITT-�� OTHER <br /> PROPERTY LINE -. PRIVATE GESTIC WELL PUBLIC I3JNESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria —Cable +Too l Dia. of Well xcavatiun <br /> Domestic/private Drilled Dia. of Well Casing <br /> —Domestic/public Dri ven - — .... -Gauge orf"C'asi'-ng -'-- - <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H• <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: (State fork 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. Horne 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 CA OR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE: DATE <br /> (DRAW PLO, PL-AN ON REVERSE DE a <br /> ORD ARTMEN USE ONLY <br /> PHASE I <br /> .ICATION ACCEPTED BY DATE <br /> i,W,>ITIONAL COMMENTS: <br /> PHASE II GROUT SPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY OAT � Y <br /> EN 1426; Rev. 12-77 <br />