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SAN JOAQUIN LUC8L HLALIH FOg OFFICE USE: U15Ixl`95205 Permit No.78- /�� <br /> 1601 E. Hazelton Ave,. , Stockton, CA <br /> Telephone: -(209) 466-6781 <br /> Al Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex' ires 1 Year From Date Issued ` <br /> (Cori ipl ete In Tri pl i cater <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install tree work herein described. - This• app.licatlon is made in compliance with San <br /> ,'oaquin- County Ordinance No. 1862 and .the Rules and Regulations of. the San Joaquin Local Health <br /> District. <br /> Ex ACT STREET ADDRESS �Ir�,es 4 �� CITY/TIM <br /> Phone <br />' Owner's Name <br /> AddressS w City I <br /> License <br />` Contractor' s Name 'Y1' �°L � q Phane �� <br /> IS CERTIFICATE OF,WORKMAN'S COMPENSATION INSURANC Ora FILE WITH SJLHD? YES NO <br />. TYPE OF -WORK (Check) : -NEW WEL:C OR� 'DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLINATION Q WELL ABANDONMENT E3 OTHER <br /> 0 <br /> PUMP INSTALLATION PUMP REPAIR L PUMP REPLACEMENT 0 <br /> 6 <br />. DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES/ ZO + PIT PRIVY 'S <br /> SEWAGE DISP �LD <br /> RTY CESSPOOL/SEEGE PIT aMESTICRWELL <br /> PROPELIN�-. RIVATE DOMESTIC WELL PUBLIC DO <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/privateDrilled Dia. of Well Casing <br /> ;Domestic/public —Driven Gauge of Casing d y c <br /> Irrigation Gravel Pack Depth of Grout Seal O <br /> Cathodic Protection Rotary Type of Grout a.r� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor M00 mot?',, <br /> Type of Pump H.P. <br /> f <br /> , 11MR11PLA11MINT: [] State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure <br /> fI hereby certify that I have prepared this application and that the work will be done in accordanc <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 /> k "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 /> 11 WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: S r, DATE: <br /> flR W"PLOT PL N ON REVERS SIDE <br /> FOR DEPART ENT US ONLY <br /> PHASE I *� DATE S <br /> APPLICATION ACCEPTED BY ---� <br /> ADDITIONAL- COMMENTS: Y <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY— __ DATE <br /> ru 7 AOC Do .19-77 /-.7_8 2M <br />