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-• = SAN JOAQUIN- LOCAL HEALTH DISTRICT <br /> `FFICE SSE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> i APPLICATION FORkWELL CONSTRUCTION OR PUMP PERMIT. Date Issued 67 <br /> 1 <br /> (Complete In Triplicate) + <br /> Application is hereby made to the San Joaquin Local Health District for a permit 'to construct <br /> and/ori.install the work herein described. This application is made in- compliance. with San <br /> Joaquin County Ordinance .- <br /> No : 1862 and the Rules and Regulations -of the Sant Joaquin Local Health <br /> District. <br /> r <br /> EXACT` STREET ADDRESS G S� ",,, CITY/TOW <br /> f Owner's Name ✓ Phone <br /> Address .City___ �.c��� SAL, <br /> .. �,.. .._ . _.__.__._,..,.. <br /> Contractor' s Name S 7c� License# /93 71,k- Phone_ 462 --262-6 _ <br /> F -IS CERTIFICATE OF WORKMAN'S CO " EN ATION INSURA+SCE ON FILE WITH SJLHD? YES - NO <br /> [ TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION 0 DESTRUCTION[n ._ <br /> ! WELL CHLORINATION Q WELL ABANDONMENT Q OTHER 0 <br /> _ PUMP INSTALLATION 0 PUMP REPAIR[?' PUMP REPLACEMENT'Q _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ ., ,. PIT PRIVY Y v <br /> SEWAGE DISPOSAL FIELD CESSP L/SEEPAGE PIT OTHER' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ' <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> .4 ndustrial Cable Tool Dia.. of Wel Excavation <br /> Domestic%private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> x Irrigation � . - Gravel Pack Depth of Grout Seal <br /> Cathodic. Protection Rotary v Type of Grout - <br /> Disposal Other Other Informalion� <br /> Ge-ophy�sica.l rv. „� Surface Seal Installed by: <br /> ' PUMP INSTALLATION: <br /> T 'Type of Pump _ ,. _ , H.P. <br /> PUMP REPLACEMENT: ' ❑State Work Done <br /> PUMP REPAIR: WState Work Done � , ,,1 � - C A" <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and 'that the work will be done in accordant <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 INSPECTION ftP R TO GROUTING AND A'FINAL INSPECTION. <br /> I SIGN "TITLE: ATE: <br /> D Vl-�172 <br /> W PL N ON REVERSE SIDE.),,­-- <br /> FOR <br /> IDE ,,---FOR D9PARTMENT USE ONLY ri?VR I <br /> PHASE I <br /> APPLICATION ACCEPTED BY TE <br /> ADDITIONAL COMMENTS: <br /> PHASE IF-GROUT I PHASE III FINAL INSPE TION <br /> INSPECTION BY .DATE INSPECTION BY DATE <br /> .EH 14 26 Rev. 9/78 __ :., s 9/78 2M <br />