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DISTRICT <br /> SAN JOAQUIN LOCAL HEALTH <br /> FOR.,. f.FICE_USE: "j .: s° 1601 %&H zt-4,e,I ton Ave: , Stockton, .CA 95%ER',!T: <br /> Permit No. . <br /> t <br /> Telephone: (209) 466-6781 <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP <br /> Date Issued 6.2(,-79 j. <br /> ,(Complete In ,Triplicate) i . .. <br /> App1-ication' it hereby. made to' the San Joaquin Local Health Di,trio or :a permit .to constru t <br /> and/or install the work herein described. This app'lic'ation. is made .ins. compliance with San <br /> Joaquin,.'County, Ordinance No. 1862 and,,the Rules and-Regulations of the .San Joaquin,Local Health <br /> District. ,�/ <br /> k ��rl�v�7S'/� -` { CITY%TOWN' Cr�v,�e�� <br /> EXACT pSTREET ADDRESS ,. ./"J� 5..So_ -ofw g CI d- _ <br /> Owner' s Name 6,6 7 'r 7; �2` � ,r Phone <br /> Address F r City t <br /> o <br /> LicensePhone <br /> Contractor's Name- <br /> IS <br /> ame v1 C Dh3 <br /> I5 CERTIFICATE `OF 106 KMAfd'S COMPENSATION INSURANCE. ON FILE' WITH SJLHD? YES NO <br /> TYPE_,OF .WORK .(Check)S: ` NEW WELL DEEPEN Q '-460ITION ❑ ,. - DESTRUCTION / / <br /> WELL;CHLORINATION 0 WELL ABANDONMENT Ci OTHER 0. , eo e_ <br /> C- <br /> PUMP REPLACE T <br /> PUMP INSTALLATION Q ,P-UMP REPAIR❑ <br /> DISTANCE TO NEAREST: SEPTIC .TANK. SEWE=R LINES PIT :PRIVY r .. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPRGE W OTH.ER. ; <br /> PROPERTY LINE - PRIVATE ,DOMESTIC WELL UBLIC DOMESTIC WELL. <br /> INTENDED .USE- TYPE OF WELL STRUCTION SPECIFICATIONS <br /> Irndustri-al Cable Too Dia. of ell,. Excavation <br /> '� <br /> Domestic/private Drilled Dia. Well Casing 0M0— ' <br /> Domestic/public, Driven Ga of`'Casing �. <br /> Irri gain on Grave k ' D th of Grout Seal <br /> Cathodic Protection ��Rotar ype of- Grout <br /> Disposal 0 e Other Infor.-mat•ion <br /> - . <br /> Geophysical Surface Sealrylnstalled b :` <br /> PUMP INSTALLATION: Contracto <br /> Type of P <br /> PUMP REPLACEMENT: � Sta Work. Do <br /> PUMP REPAIR: S e Work one ' <br /> DESTRUCTION OF WEL : We 1 Diame Approximate Depth '- <br /> Describe' terial and Procedure <br /> ,Thereby certify that 'I ha v prepared this application and .that the work will. be .done in accordce <br /> with San Joaquin County Or nances , State Laws , and Rules and Regulationsof the -San Joaquin Loll <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 'a•ny person in such manner 'as to become subject to- WorkmanJ-�pensation <br /> laws of California . " <br /> 'I -WILL CALL FOR A �GRQ2T INSDECTION PRIOR TO GROUTING.AND A FINAL INSPECTION. <br /> DATE: <br /> SIGNED TITLE: —' <br /> DRAW PL T PL N ON REVERSE. SIDE <br /> FOR DE RTMENT USE ONLY •' <br /> PHASE 'I. r <br /> APPL-ICATION ACCEPTED';.BY DATE 7 <br /> ADDITIONAL COMMENTS : <br /> PHASE -Ii GROUT INSPECTIONPHASE III FINAL- INSPECTION• <br /> ::INSPECT1ON' BY, , DATE INS TION BY " DATE' � <br />�11i 19, 26 Rev. 9/78 5/79 2M <br />