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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE `USE:' ` T 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. - <br /> Tel'ephorie:, (209) 466-6781 <br /> APPLICATION EOR' WELL CONSTRUCTION--OFC PUMP PERMIT Date Issued -/ <br /> .(fomplete In Triplicate) i <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 in compliance with °San <br /> Joaquin County Ordinance No. 1862 and the Rules and_ Regulations ,of the San Joaquin Local Health <br /> District. k.. <br /> EXACT STREET ADDRESS I9 C - 1r)l)•s CITY/TOWN S CPA <br /> Owner'S Name Phone <br /> Address <br /> Contractor's Name <br /> ty- <br /> ;License# Phone <br /> IS CERTIFICATE OF WORKMAN S CO+�1P_ENSATION INSURANCE-ON-FILE WITH SJLHD. 'Y E'S J <br /> O <br /> TYPE OF WORK (Check) : NEW WELLLJ DEEPEN ❑ : RECONDITION DESTRUCTION il <br /> .. <br /> M WELL CHLORINATION 0 .WELL ABANDONMENT [:] OTHER O <br /> PUMP INSTALLATION M PUMP REPAIR 0 " PUMP .REPLACEMENT Q <br /> DISTANCE TO -NEAREST: SEPTIC TANK SEWER LINES PIT; PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER` » <br /> PROPERTY LINE `- PRIVATE DGRESTIC WELL_ PUBLIC DOMESTIC WELL <br /> .. INTENl E <br /> Industriatrial TYPE OF-WELL.; CONSTRUCTION SPECIFICATIONS <br /> : Cable Tool Dia. of Well -Excavation _ . �' 1 <br /> --w------��f <br /> Domestic/private -,� ��Drilled Dia, of Well Casing <br /> - .•-Domestic/public ti Driven Gauge of Casing <br /> Irrigation <br /> - Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical .r. Surface Seal Instal ed b <br /> PUMP INSTALLATION: ' ' Contractor - - <br /> Type-TypePump - <br /> 04 <br /> ` H. . <br /> LUMP AEPLACEM£NT: []State Work Done <br />!PUMP REPAIR: O State Work Done ` <br /> DESTRUCTION OF WELL: Well Diameter � <br /> Approximate Depth `S r <br /> Describ Materia and Proce ure. k C e e <br /> I hereby certify that I ha a prepared is application and that- the work will be done in 'accordano <br /> with `San Joaquin County Ordinances ; State Laws , and Rules and Regulations. of. ihe San_Joaquin :Locall <br /> Health District. Home owner or licensed agent's signatur'e '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 be <br /> laws of California. " ., come__subject to .Workman'.s Compensation <br /> .k = -�~ r �--`p <br /> I WILL CA FOR A G OUT INSP CTION PRIOR TO .GROUTING -AND A FINAL INSPECTION. <br /> SIGNED ry <br /> TITLEATE <br /> DR W PLO L N ON REVERS SIDE <br /> RHASE I R` DEPARTMENT USE GNLY <br /> APPLI ATION ACCEPTEDBY ' <br /> kDDITIONAL COMMENTS: DATE h <br />: ;. <br /> PHASE II GROUT INSPECTIONPHASE III SINAL INSPECTION <br /> ECT!ON BY' DATE ' <br /> IN BY DATE -79 <br /> j26 Rev. 9/78 , <br /> 9/78 = 2M <br />