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SAN JOAQUIN`LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton.Ave. , Stockton, CA 95205 Permit No. S- / <br /> Telephone: (209) 466-6781 pate Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ices 1 Year From Date issued ; <br /> Complete In Triplicate 4s <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 /> r district. <br /> EXACT STREET ADDRESS SO® #: CITY/TOWN tiS <br /> e0ZPhone <br /> Owner's Name " Al. <br /> Address .s / -�-�=-- <br /> C i tya. 0 <br /> _Contractor's Name Licens Phone <br /> GC = .., -.. <br /> IS CERTIFICATE OF WORK11AN'S COMPENSATION IidS.URAtlCC ON FILE 1r1ITH SJLHD? Y NO <br /> TYPE OF WORK (Check) : NEW WELl�1 'DEEPEN ❑ RECONDITION Q DESTRUCTIONFI <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION E] PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> PIT OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEE <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE . TYPE OF WELL CONSTRUCTION SPEC FICATIONS <br /> Industrial" ' """ "� - _`-Ca le`Tool -"`Dia: of­W 11 "Exczv�at'i-o-n <br /> Domestic/private 3!Drilled Dia. of Well Casing , <br /> Domestic/public Driven - ' Gauge of Casing d <br /> I _ Irrigation Gravel Pack �-° Depth of Grout Sea �S O.4- <br /> ! Cathodic Protection Rotary Type of Grout <br /> Disposal .Other Information <br /> Geophysical w� -.,/Surface Seal Instal ed b <br /> . - - Pte. <br /> PUMP INSTALLATION: Contreactor <br /> Type `of Pump H.P. ? ' <br /> PUMP REPLACEMENT: []State Work Done <br /> s <br /> PUMP REPAIR: Q State Work Done ` <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure <br /> 4 I hereby certify that I have prepared this application and that the work will be donelin 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 R A UT INSPE ION PRIOR TO GROUTING AND �FI, ALINSPECTION.SIGNED 1 'TITLE': _ w �DATE:ii 5 'W PLOT PL N ON REVERSE SDE <br /> FOR DEPARTMENT USE_ ONLY,.—\ <br /> PHASE I / DATE �f� W <br /> . APPLICATION ACCEPTED BY d( <br /> { ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -S.- / ) <br /> 1 /78- --2M <br />