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-- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F . 1601 E. Hazelton Ave. , Stockton, CA 95205 Permi t No.7 9- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION .OR PUMP PERMITDate Issueds-i4 -72 <br /> (Eoinplete In`Tr.iplicate) <br /> Application is hereby made to ..the S.an.,Joaqui.n 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. I862. and :the :Rules and' Re.gulations of the 'San Joaquin Local Health <br /> District. 1 <br /> EXACT STREET ADDRESS - �.. - C� .. °� j- <br /> CITY/TOWN.. <br /> Owner's Name . Civef �.e Phone 1 <br /> AddressCity AEke= <br /> Contractor . � <br /> ' _ � � <br /> s Name 'y� Li cense# Phone "' , <br /> ti - <br /> -IS- CERTIFICATE -OF-WORK"IAN-`.S--CO ,P£NSATIO"I—INSURA"�ICE ONuFIL WITH-SJLHD?� YES 1C No. - <br /> TYPE OF WORK (Check, : NEW WELL L DEEPEN 0 ,, RECONDITION [] - DESTRUCTION d <br /> WELL CHLORINATION -n WELL ABANDONMENTED OTHERE3 ` <br /> ` PUMP INSTALLATION El PUMP. REPAIR99`' -PUMP REPLACE FNT-Q <br /> . r <br /> DISTANCE TO NEAREST: SEPTIC' TANK SEWER LINES PIT PRIVY ., <br /> t �SEWAGE DISP SU AL FIELD CESSPOOL/SEEPAGE PIT -OTHER.- \ <br /> PROPERTY LINE - PRIVATE D MESTIC WELL PUBLIC D MESTIC WELL <br /> �- INTENDED USEf� k; . TYPE OF-.WELL.., CONSTRUCTION SPECIFICATIONS <br /> Industrial _ _ 'Cable Tool -Dia. of Well Excavation .-. \� <br /> Domestic/private t_ .Dri',l1ed ' Dia. of We11 Casing <br /> Domestic/publ;ic ' `Pr,iven Gauge. of Casing <br /> Irrigation Gr`a`vel Pack Depth of Grout Seal.. , <br /> Cathodic -Prot ection Rotary Type of Grout - <br /> Disposal ;` . Other I Other Information <br /> Geophysical , ry ., . j ° Surface Seal Insta ed <br /> PUMP INSTALLATION: -Contractor l <br /> Type of Pump HT <br /> PUMP REPLACEMENT: ;k Q State Work Oone, <br /> Ap <br /> apU PrREPAIR: = ' a r . - <br /> f�fState "Work-Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ' Describe Material and Proce ure <br /> I hereby certify l. e. <br /> I.,havp-r-epared:tthis-:appl:icatioi!Y and-'t'-hat?the-,wo�^k-_w�-11-"be--�done in accordant <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the. San Joaquin- Local <br />' Health District. Home owner or licensed .agerit's signature certifies the following: <br /> "I certify that inT,the performance of the" workffor which °this permit is issued, I shall <br /> ; not!'employ-any person in such mariner as `to`become subject to Workman's Compensation <br /> ' laws of California:'` , <br /> 1-WILL CALL FOR 'A `GROUT; INSPECTION PRIOR TO- GROUTING AND A FINAL INSPECTION. <br /> SIGNED ` - - *l. i TITTLE: DATE:. <br /> RAW PL L N ONREVERS DE <br /> FOR JDEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCIEPTED BY` - .DATE " 77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAA I L - INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE � <br /> SEH 14 26 Rev. -,9./78 T, - I . .Sl �9/78 2M <br />