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SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave.:; Stockton, CA 95205 Permit No.ZLza?�--1 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR TELL CONSTRUCTION OR PUMP PERMIT Date issued 3 3 " <br /> This Permit ,Expires 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 i.n .compliance with San <br /> ,'oaqu,i n County Ordinance No.-: 1862 and . the Ru' <br /> s and Regulations- of the: . an Joaquin Local - Health <br />..CDistrici. C I G Lr4 "a /I�sN;Ak"w- d#t.G'w:,�_.��+ <br /> EXACT STREET ADDRESS D 1, 6 w CITY/TOWN <br /> Owner's Name9 Phone Y,� - 3 3 <br /> Address_ VUCity�7 �a /I <br /> Contractor ' s Name LicensegJ- ' 71 Phone <br /> IS CERTTFICATE OF ORKNAN�S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES —NO'.. <br /> TYPE ,OF WORK (Check) : NEW WELLb4 DEEPEN ❑ RECONDITION ❑ DESTRUCTIONC3 <br /> s WELL CHLORINATION ❑ WELL ABANDONMENT p OTHER l-1 <br /> ,PUMP INSTALLATION E] PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANC£`TO ,NEAREST: \SEPTIC 'tANK/d d , 'SEWER LINES& b PIT PRIVY- <br /> N SEWAGE,.DI-SPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL '- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 14917 <br /> ,F,�,D6mestic/private _'�7`Dri11ed Dia. of Well Casing 'r <br /> Domestic/public Driven - Gauge of Casing Azn <br /> Irrigation Gravel Pack Depth of Grout Sea] s'o ' <br /> Cathodic Protection Rotary Type of Grout r <br /> Disposal Other Other Information <br /> .Geophysical Surface Seal Installed b <br />'PUMP INSTALLATION: Contractor air <br /> Type of Pump H.P. <br />' PUMP REPLACEMENT: O State Work Done. <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 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 California. " <br /> I WILL CALL FOR A GROUT SPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. ' <br /> SIGNEDeAX TITLE: "= DATE: 0- 7 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> . . - _ _ .� <br /> FOR DEPARTMENT VSE ONLY <br /> PHASE I —. <br /> APPLICATION ACCEPTED BY DATE as 7e . <br /> ADDITIONAL COMMENTS <br /> PHASE IT GROUT INSPECTI PHAS II INSPECTION <br /> INSPECTION BY DATE a INSPECTION BY DATE ]fL e <br />`EH 1426 Rev. 12-77. . ,.. .. .. _ <br /> 7V T./78 2M. <br />