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SAN JOAQUIN LOCAL HEALTH DISTRICT --�—� <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 1I�13� <br /> (Complete .In Trip-licate), <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. <br /> ACT- �TRrEET ADDRESS �/p � 6 �� :' 'f"��P, SL,��FTY%TOWN eke kfeMD <br /> �''' °l� °e ePhon LwA <br /> - <br /> _-T <br /> Address .� Gr 4/ Q' , „, ." " City e <br /> Contractor's Nam 4 y ' ' cd _License Phone o <br /> eL� �Cd� UTa �S <br /> a :moi �. <br /> IS CERTIFICATE OF WOR '- ""� - _ — _. ._ NO <br /> Kt1A�J�5 CO���PENSATIOPJ° IPJSURA?1C�-_ON__FILE WITH SJLHD? YES `� <br /> TYPE OF WORK (Check) : NEW WELLP< DEEPEN El RECONDITION [3 DESTRUCTION En <br /> WELL CHLORINATION Q WELCABANDONMENT 0 OTHER 0 GIS <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK/&L SEWER LINES . .,.`-" PIT PRIVY — <br /> SEWAGE DISPOS L�FIELD ave CESSPOOL/S EPACyE PIT OTHER -- ' <br /> PROPERTY LIN PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ` INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT ONS <br /> Industrial - Cable Tool Dia. of Wel Excavation 1,Z11.2 <br /> Domestic/private' Drilled Dia. of Well Casin " <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation-�.s---- �. Gravel -Pack "'" Depth `of"GroU'F! a ° a Cis rn+` <br /> Cathodic Protection- -", —Rotaryy Type of Grout <br /> Disposal 111 ; Other -s. Other Information <br /> ' Geophysical 4 Surface Seal Installed by <br /> i :PUMP INSTALLATION:. Cojwtrr-ac-t-6.gn_ - e <br /> Type of Pump i&z H.P. - <br /> PUMP <br /> . .PUMP REPLACEMENT: []State Work Done / <br /> PUMP REPAIR: C3State Work Done „ ��- <br /> DESTRUCTION OF WELL: Well Diameter - Approximate ,Depth <br /> 1{ 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 .Ru1e�and--Regal-ati-ons of-the San-Joaquin Local <br /> } ealth- District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that in the performance_ of,�.the_work.._for:whi_ch-this permit is issued, I shall <br /> not employ any person in such manner astto- ecome subject to Workman's Compensation <br /> laws of California:" <br /> I WILL ..CAL FOR A GRQJJTINS ECTIO PRIOR TO GROUTING--AND A FINA INSPECTION,. ' <br /> SIGNED - -= TITLE DATE: . 71� <br /> (DRAWZZ PLOTTL7NqON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I. , <br /> APPLICATION ACCEPTED 'BY DATE, / <br /> ADDITIONAL COMMENTS: <br /> PHASE. II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> f INSPECTION BY c ' _- DATE, .`�.'INSPECTIQN"° BY `' DATE 7-9`7 <br />► EH. 14 26 Rev. 9/78 - C09/78 2M <br />