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- --9.......�,�.. .... �- . <br /> ��1 ourA toncro �e..trc ,� <br /> 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 �, <br /> '(t;omplete In Triplicate} ; <br /> Application is hereby made to the San Joaquin Local Health vDistrict fora 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 Heal-th <br /> bistrict. <br /> EXACT' STREET ADDRESS / <br /> - �- CITY/TOWN CSDd� <br /> Owner's Name - Phone <br /> Address—, O. - <br /> _. ..City <br /> Contractor's Name / License# /M' 7;,� Phone . �6 ' _4 <br /> :IS CERTIFICATE 'OF Q RKMAN'S COMPS TI N INS'URA"rlCE ON FILE WITH'SJLHD7 YES y 0 <br /> TYPE OF WORK (Check) : NEW WELL C1 DEEPEN El RECONDITION DESTRUCTION Ej : _< <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER(,] <br /> PUMP INSTALLATION [) PUMP RfEPPAIW6AV PUMP REPLACEMENT [] <br /> ,bISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES ...,, PIT PRIVY <br /> SEWAGE DISPOSAL FIELD GESSP OL/SEEPAGE PIT OTHER, <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ---- PUBLIC DOMESTIC. WELL � <br /> INTENDED" USE. TYPE OF WELL CONSTRUCTION SPECIFICATIONS flI <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �Oomestic/private Drilled Dia. of Well Casing. , <br /> A D,omesti-c/public Driven Gauge of Casing <br /> �Irr gti-ons Gravel Pack Depth of Grout Sea <br /> `TCathodic .Protection Rotary Type of Grout - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Inst_ ed 7b- <br /> LUMP <br /> :PUMP INSTALLATION:. Cont.racf-br <br /> Type of Pump u - H.P. <br /> PUMP REPLACEMENT: p.State Work Done <br /> SUMP REPAIR: ®State,-Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an 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 Rules and Regulations of the -San -Joaquin Local <br /> Aealth 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 /> LSIG]NE <br /> WILL CA L FOR A GROU NS E -1� RIO . TO GROUTING ANDrA'FINAL INSPECTION. <br /> TITLE: DATE: <br /> 114 <br /> PL L ON REVERS SIDE "" <br /> /Z. 2 — <br /> PHASE I 1/ OR DEP RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATEy <br /> ADDITIONAL COMMENTS: , /.? <br /> fINSPECTION BY DATE PHASE II ROUT INSPECTION -� PHASE I I FZNA iNSPE TION 11 <br /> CH J 26 Rev. 9/78 PH, <br /> E I N BY DATE . a k a <br /> —�Y <br />