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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton-Ave. , Stockton, CA 95205 Permit No.Z -/ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/.)- -J <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 %Uld� CITY/TOWN <br /> Owners Name Phone gg_7 y <br /> Address <br /> C-i ty-I <br /> Contractor's Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION I SURANCE ON FILE WITH SJLHD? YES NO. <br /> TYPE OF WORK (Check) : NEW WELL[Q DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR[3-L- PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANKm�or� SEWER LINES_Sol♦ PIT PRIVY <br /> SEWAGE DISPOSAL, IELD + CESSPOOL/SEEPAGE PIS OTHER <br /> PROPERTY LINEAL-4PRIVATE DO ESTIC WELL-,SA' Li_ PUBLIC D MESTIC WELL �-- <br /> INTENDED USE TYPE OF.WELL_ CONSTRUCTION SPECIFICATIONS <br /> Industria Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing r <br /> _ Domestic/public Driven Gauge of Casing of . <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of GroutC. ,,� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta e K <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. - <br /> PUMP REPLACEMENT: F]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 FOR ROU INS �NP. IORTO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: 14- c.u1'L DATE: 12- ,zt <br /> (DRUTLOT PUff ON REVERSE SIDE <br /> PHASE I F R D£ RTMEN USE ONLY <br /> PPS' LICATION ACCEPTED 8Y DATE --7// <br /> 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE IIGROUT INSPECTION PHAS5-1JI 'fWL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3 7 <br /> EH 14 26 Rev. 9/78 - g/ 2,M <br />