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/ SAN JOAQUIN. LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , .Stockton, CA 95205 Permit No.�� -- <br /> Telephone: X209). 4667.6781 Date Issued <br /> 3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit'; Ex ices 1 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. � <br /> EXACT STREET 'ADDRESS CITY/TOWN <br /> �3 <br /> Phone <br /> Owner's Name <br /> City <br /> Address : .. � ,� �i l4 e ��� _ . Je Contractor' s Name /' LicenseZO,Z�� Phan <br /> i <br /> 14 I5 CERTIFICATE OF 1dORKIIAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK: (Check) : NEW WELL 5a DEEPEN Q WELRECONDITION N�4EN®C7 DEOTHERION CI <br /> WELL CHLORINATION L7 , <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> DISTANCE TOY-NEAREST: SEPTIC TANK SEWER LINES PIT PRIVYH <br /> SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT� UTHER_r <br /> PROPERTY LINE PRIVATE DOMESTIC WELL — -- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL F CONSTRUCTION SPECIFICATIONS <br /> : Industrial Cable Tool Ma. of Well Excavation <br /> Domestic/private Drilled ; Dia. of Well Casing _ <br /> Domestic/publi'c"' Driven AGauge of Casing <br /> Irrigation Gravel Pack -i Depth of Grout Seal <br /> Cathodic Protection Rotary Type- of Grout f® <br /> Y Disposal `"" 'F" ` � - Other Other. Information, <br /> Geophysical - /. 'Surface Seal Installed by: r <br /> PUMP INSTALLATION: Contractor rl r �- <br /> ° t Type of Pump H.P. <br /> PUMP' REPLACEMENT: p State Work- Done <br /> PUMP REPAIR: 1 Q State Work'Done ` <br /> Y — ­--- a Approximate Depth S <br /> DESTRUCTION OF WELL: Well Diameter <br /> Descr*be Material an Proce ure -� <br /> I", hereby certify that I have prepay d thi application and that he work will be done in a ordanc <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' se-ignature 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 /> t laws of California." <br /> ' TWILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE: /1 �� DATE:���-� ! 7r <br /> SIGNED <br /> DR �PrLL �PrLL N ON REVERSE SIDE <br /> } FOR DEPARTMENT USE ONLY <br /> PHASE If 2� <br /> APPLICATION ACCEPTED BY /tc� DATE <br /> ADDITIONAL COMMENTS: <br /> P I f.ROUT INSPECT.IO -r RHASE III FINAL- LNSPECTION <br /> iINSPECTION BY DATE I INSPECTION BY ` DATE Z <br /> � . w <br /> -1/78 -_ 2M <br />