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SAN JOAQUIN: LOCAL HEALTH DISTRICT ` <br /> FI.CE USE:. ' !/` 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No <br /> Telephone: (209) 466-6781 <br /> on <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -y' <br /> . y <br /> (,Complete . IC ri pl i cate) <br /> ;Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> gaud/or install the work herein described. This application is made in compliance with San <br /> ,Joaquin County Ordinance No. 1.862 and the Rules and' Regulations of the San Joaquin Loc'a1 Wealth <br /> ,Di strict. /Roo Al, BroeA", . <br /> ;EXACT STREET ADDRESSCA Zjggg rre irg CITY/TOWN:0�aC/i~ Do A-' <br /> Owner's Name Phone f�e6 Z _ ,_ sSe© <br /> :Address t <br /> Ci <br /> Contractoris< Name � icense# Phone 'I I�-„ 3�' � <br /> ' F <br /> ITS CERTIFICATE- OF WORKMAN'S COAMPENSATION INSURANCE 0 FILE WITH-SJLHD? YES NOc�7�. � <br /> TYPE OF WORK (Check) : NEW WELL UJ-- DEEPEN ❑ RECONDITION [3 DESTRUCTION <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 n . <br /> PUMP INSTALLATION 0 PUMP REPAIR 0 PUMP REPLACEMENT U <br /> DISTANCE TO NEAREST: SEPTIC TANK/5&41 SEWER LINES PIT PIT PRIVY n <br /> SEWAGE DISPOSAL IELDJ�Q ' CESSPOOL/SE PAGE PI�� OTHER <br /> PROPERTY LIN PRIVA ET DQ ESTIC WELL/ PUBLIC D MESTIC WELL - p <br /> INTENDED USE TYPE OF-WELL.., CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation , <br /> Domestic/private Drilled Dia. of Well Casing . <br />` <br /> D,omesira.c./_publ i-c . ... -- - <br />�— Driven- _ Gauge o asing , <br /> - —Irrigation Gravel Pack Depth of Grout Sea i <br /> Cathodic Protection <br /> ___D <br /> _ Disposal e-;:;rotary Type of Grout <br /> Other Other Information ; <br /> I -i-�Gegphysical; Surface Seal Insta b ;. <br /> ed <br />�UM-�TALLATION:� Contractor. ' <br /> Type of Pump H. <br /> P.,IUMP ,REPLACEMENT: In <br /> State Work Done <br /> PRJMP 'REPAIR,., ! ....Y ., f <br /> ❑State Work Done, <br /> '�' <br /> D;E§TRUCTION OF WELL.: <br /> Well biameter ' <br /> - App,roXimate Depth , <br /> y► ;� Describe Mater.ial and ProcedureV. <br /> #q- <br /> I: Hereby certify that I have;-prepared this application 'and that the work will be done in .accordance, <br /> gir th San Joaquin County Ordihances., State Laws , and Rules and Regulations of the_San_Joaquin�Locaf <br /> Meal th Di.itri ct.::�..Home-owner-L or 1 i-censed-agen-t"-s-!i:gnature certifies the following: <br /> �- �-- <br /> ;�._I�certify that in the performance of thework -for` -which this permit is issued, I shall ' <br /> snot e Ploy any person in such manner as to become subject to Workman's Compensation i <br /> laws Of- California..” <br />[ ^WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />:GNED <br /> TITLE: _ DATE: <br /> R W T L N ON RE RSE SIDE <br />'RASE I FOR D-EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 9 �1 <br /> iD,DITIONAL COMMENTS: �PHASE <br /> I.I GRNSPECTIONa <br /> PHASE III. FINAL INSPECTION <br /> NSPECTION BY <br /> DATE INSPECTION BY DATE ` <br /> H 14 26 Rev. ,9/78 9/78 2M` <br />