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5AN JUAQUIN LULAL HtHL 111 Uig 1 Kil,1 Permit N0. e ' a <br /> : OFFICE USE: 1601 E. Hazelton Ave. ,._ Stockton, CA 95205 <br /> Telephone: {`'09).�"�66-6781 <br /> APPLICATION FOR DELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> f <br /> Complete 5 Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a perm nce <br /> to construct <br /> p <br /> ith San <br /> and/or install the work herein described. This andlReaulationsmade <br /> the SanpJoaquinwLocal Health <br /> Joaquin County Ordinance No. lia <br /> 1862 and the Rules 9 JS�OS <br /> District. CITY/TOWN5 0 - <br /> EXACT' STREET ADD RES S__6 Phone <br /> Owner's Name142City <br /> Address _ <br /> License#??/l <br /> Contractor's Name _ Phone <br /> IS CERTIFICATE OF WORKMAN`s COMPENSATIO�1 ItAUR elCE ON FILE WITH SJLHD? .YES NO_____-___ <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN[J RECONDITION ❑ DESTRUCTION[� el <br /> . WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER <br /> 0 <br /> PUMP INSTALLATION 0 PUMP°REPAIR(--3PUMP REPLACEMENT [I C <br /> DISTANCE TO NEAREST: SEPTIC TANK sv SEWER LINES-_.-� PIT PRIVY 0 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINFI '�RIVATE DOMESTIC WELL- PUBEIC'DOMESTIC WELL' <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia of Well Excavation. /Q " -- <br /> Industrial , <br /> Domestic/private Drilled Dia. of W611 Casing <br /> Driven Gauge of Casing <br /> _ Domestic/public �Irrigation =Gravel Pack Depth�of Grout Seal �v r' <br /> Cathodic Protection Rotary Type of Grout__r__ <br /> + Other Information <br /> Disposal Other <br /> Geophysical Surface Seal Insta ed b <br /> PUMP INSTALLATION: Contractor H' <br /> ( Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and ProceRure <br /> I hereby certify that I have prepared this application and that the work will be done in accords <br /> with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Loc <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 5 C 0 PRIOR TO GROUTING AND A FINAL INSPECTION. , <br /> SIGNED , <br /> — DATE: <br /> TITLE: <br /> pR W.PL P S <br /> N ON REVS SIDE <br /> FOR DEPARTMENT USE ONLY / <br /> PHASE I DATE 'y / <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMS TS: <br /> pII GROUT INSPEC ON PHASE III FINAL I SPE ION <br /> INSPECTION SY DATE - IN5PECTION BY DATE_ <br /> EH <br /> 1/78 2 <br /> 1426 Rev: 12-77,. w <br />