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- ` SAN JOAQUIN LOCAL HEALTH 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 �- t2^? <br /> This Permit Expires I Year 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 /> ,.oaq;:in County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Distr�ct. <br /> i <br /> EXACT STREETADDRESS CITY/TOWN <br /> Owner's Name Phone S7Z Y f' <br /> Address City <br /> Contractor's Name Licenst? 2 Phone� . fjy <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO; <br /> L INSURANCE ON FILE WITH SJLHD. YES NO <br /> TYPE OF WORK '(Check) : NEW WELL EEPEN ❑ RECONDITION r7 DESTRUCTION-C1 <br /> WELL CHLORINATION Q WELL ABANDONMENT E] OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP -REPLACEMENT p <br /> DISTANCE TO NEAREST: SEPTIC TANK / -EWER LINES' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD , CESSPOOL/SEEPAGE PIT OTHER <br /> y PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL `q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled. Dia. of Well Casing <br /> Domestic/public, Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout'Seal�- a <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surfdce Seal Installed b <br /> PUMP 'INSTALLATION: Contractor . -�- <br /> Type of Pump <: H.P. <br /> PUMP ,REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: []State Work Done`-' 1 ;a <br /> DESTRUCTION OF WELL: <br /> Well Diameter �Appi^oximate- Depti - <br /> Describe' Material and Procedure y { <br /> I hereby certify that I have prepared this application and 'that the work .w-ill 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: 5 <br /> "I certify that in the performance of the work for which this permit is issued, I shall i <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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. } <br /> SIGNED TITLE: DATE:*g f <br /> DRAW PL T PLAN ON REVERSE SIDE <br /> FOR DEPART ENT USE 0 Y <br /> PHASE I <br /> APPLICATION'ACCEPTED BY DATE *7�d -.4 - -1 -6 N, <br /> ADDITIONAL COMMS S: <br /> PHPAE II GROUT SPECTIO PHASE/UI F N IN PEf C ION <br /> INSPECTION BY AAdATE INSPECTION BY DATE 7� 1 <br /> s 4 <br />