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{ <br /> � � J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> Date Issued/t-�,pe 7 f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> '(t:omplete 'In"-Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a-permit -to- construct J1 <br /> 'and/or.. install the work herein descri'bed: This application is made- inscompliance 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 <br /> . SZ d, CITY%TOWN <br /> Owner's Name Phone <br /> Address ,Ctty ,<x` ;;&,., , _S.?b ` <br /> Contractor's Name License Phone , <br /> IS CERTIFICATE OF WORKMAN'S-COMPENSATION -TPJSUR ,•,CF"ON"FILE 'WITI�-SJLHO? TYES NO, <br /> 'TYPE OF WORK (Check) : NEW WELLIX DEEPEN 0 RECONDITION DESTRUCTION� <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 GJ <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT[] <br /> DISTANCE TO NEAREST: SEPTIC=TANK� � SEWER LINES /.k..,,PIT PRIVY -- <br /> SEWAGE DISP SAL, FIELD C SSP OL/SEEPAPE. PFT OTHER -- <br /> r PROPERTY LINV 9PRIVATE DOMESTIC WELL .tom. PUBLIC DOMESTIC WELL --- <br /> } INTENDED USE TYPE OF WELL . CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. --of Well Excavation ' <br /> �Domesti c/private . Dr:i l.led.¢ Di a.�of_We1-1—Casi ng <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation �V Gravel Pack Depth of Grout Seal <br /> Cathodic Protection >ks�_Rotary Type of Grout - - - <br /> Disposal - Other. - - -.0ther.,Informati on <br /> Geophysical Surface Seal Ir(sta ed by: <br /> PUMP INSTALLATION: Contractor <br /> ..Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: Q State Work Done . .. µ <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter + Approximate Depth <br /> Describe Materi-al 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 Califor . 11 "" : , <br /> I WILL C L FOR G TAN5,4ECTION PRIOR TO GROUTING AND A"FINAL INSPECTION. v <br /> SIGNS ' <br /> TITLE: aoc DATE:_ L_&e � V <br /> (DRAW PLUI PEW ON REVERS DE <br /> x3 <br /> PHASE I FOR DEPARTMENT SE ONLY 1 _ ISd� �v <br /> APPLICATION ACCEPTED BY (tf1" J <br /> ��— DATE a P 7 L <br /> ADDITIONAL COMMENT <br /> PH II OU NSPECTI N PHASE III FINAL INSPECTION <br /> INSPECTION BY ATS <br /> INSPECTION Y DRTE l--tZ <br /> EH 14 26 Rev. �. u , <br /> /78. - - 9I7f3 <br />