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SAN JOAQUIN LOCAL ,HEALTH DISTRICT � 7 <br /> FFICE USE: 1601 E. Hazelton Aup -. <br /> ,,-,Stockton, CA 95205 Permit Na. <br /> Telephone: (269);.-466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued .5_S-7 S <br /> (tromp l-ete In Trip] i cote) <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 theRules and Regulations of the San Joaquin Local Health \ <br /> 'District. <br /> ,EXACT' STREET ADDRESS % 0 S_ CITY/TOWN sc � <br /> Owner's Name____C <br /> c , <br /> Address ! J61 �' c ... City , <br /> Contractor's Name L i c e n s eUVd_lj Phone <br /> 'IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAN ONFILE WITH SJLHD? YES O- <br /> TYPE OF WORK�(Ch eck} : NEW WELLQ DEEPEN 0 RECONDITION © - DESTRUCTION O <br /> WELL CHLORINATION 0 WELL ABANDONMENT r-) OTHER 0 p <br /> PUMP INSTALLATION Q PUMP REPAIR 0 PUMP REPLACEMENT <br />:DISTANCE TO NEAREST:: SEPTIC TAN 41 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS L� IELDf� CESSP OL/SEEP GE PIT . OTHER <br /> PROPERTY LINER PRIVATE rDO�ESTIC WELL�� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WEILL CONSTRUCTION SPECIFICATIONS <br />�Industr�al Cable' Tbol Dia. of Well Excavation 'J F <br />______ Domestic/private Drilled Dia. of Well Casing i <br /> Domestic/public Driven ' , Gauge of Casing <br /> fes- ,I.rrig ation <br /> Gravel °Pack Depth of Grout Sea .�--- <br /> Cathodic Protection Rotary Type of Grout <br /> „Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : <br /> C <br /> PUMP INSTALLATION: Contractordwv <br /> .,.: <br /> Type of Pump H. . . <br /> PUMP REPLACEMENT: Elstate Work Done <br /> PUMP REPAIR: _ ❑State Work Done <br /> DESTRUCTION OF WELL: Welly Diameter -T p <br /> Describe�Materia an Proce ure Approxtmate <br />[ 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 /> iealth 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 /> WILL CALL, FOR A RO T I S CTION PRIOR TO GROUTING AND A­FINAL INSPECTION. <br /> SIGNED D TITLE: DATE:�� <br /> PLT7L_ff ON REVS SIDE <br />'HASE I OR 'DEP RTMEN USE ONLY <br /> PPLICATION ACCEPTED BY Z1DATE <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> NSPECTION BY PHASE III ,FINAL INSPECTION <br /> DATE i✓' INSPECTION BY <br /> y 14 -26 Rev. 9/78 DATE'/4_ <br /> o I70 na <br />