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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F!:�E�FICE USE: 1601 E. Hazel ton. Ave. �Stock_ton, CA 95205 Permit No. o <br /> Telephone: , (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued,5-' !-29 <br /> (tomp1ete, In Triplicate) . .. r .... <br /> Application is hereby made to the San Joaquin Local HealthDistr.ict.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 /> 5' <br /> EXACT STREET ADDRESS / --�z�e �j CITY/TOWS; L . <br /> Owner's"Name r `/ Phone <br /> Address <br /> ' ..Ci <br /> -t <br /> Contractor'-s Name yid ty <br /> 4 `ticease Phone / C` <br /> IS CERTIFICATE 'OF WORKMAN'S COM-PENSATION INSURAN E ON FILE WITH SJLHD? YES 0 . <br /> TYPE OF WORK (Check) : E, NEW WELLga--_ DEEPEN b RECONDITION DESTRUCTION( <br /> �,;!WELL CHLORINATION 0 WELL 'ABANDONMENT 0 ;OTHER 0 <br /> y � PUMP INSTALLATION �/PUMP REPAIR CI PUMP3REPLACEMENT C S <br /> DISTANCE TO NEAREST: ; SEPTIC TAN 91 LINES. 9IT PRIVY �� J <br /> � . SEWAGE DIS OSF� AL FIELD r CESSP OL/SEEPAGE PIT -- OTHER <br /> K PROPERTY LINZQPRIVATE DOMESTIC WELL ''=PUBLIC DOMESTIC WELL <br /> INTENDED USES- � TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial C ble Tool Dia. of WeTl Excavation <br /> 4--" Domesti c/pri vate 1 T ed Dia. of Well Ca 3 rigs <br /> Domestic/public Drivm Gauge of Casing, ,"I <br /> Irrigation Gravel -Pack- ry .,,Depth of Grout Sea e9 r� <br /> Cathodic Protection rotary ° ° ,; t,+ Type of Grout <br /> Disposal Other w; Other Information <br /> .Geophysical <br /> Surface Seal Insta e b <br /> PUMP -I,NSTALLATION: Contractor .10 <br /> Type of PumpH. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR . Qstate�Work-gone— -� <br /> DESTRUCTION OF WELL: Well Diameter �• ' , ,� : ' t ' , ` `t Approximate Depth <br /> -_ Des.cribe-Maters a--an - -roce urea~--- <br /> ` a <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 . Regulati.ons ,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 California. <br /> I WILL. CAL 'F A GRO I PECTION PRIOR TO GROUTING AND A.-F. NAL INSPECTION, ` <br /> SIGNED TITLE: / DATE: l <br /> PL ON REVERS SIDE <br />°HASE I OR DEP RTMEN USE ONLY <br /> VPPLICATION ACCEPTED BY ; <br />=ITIONAL COMMENTS: d1 DATE <br /> PHASE I GR INSPECTIO PHASE Z • FINAL INSPECTION <br /> NSPECTION BY }ATE (p ; INSPECTION BY <br /> DATE <br /> ,14 26 Rev. 9/78 <br /> ,� �- o.1 a❑ n nR <br />