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,i � �r��.....--��•=—,�,-.._,.-��,e;-.may <br /> i� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E'. Hazelton Avg, , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466 -67'81 <br /> i< APPLICATION FOR WELL CONS UCTION OR PUMP PERMIT Date Issued <br /> �I (Complete In Triplicate) <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. �I <br /> EXACT STREET ADDRESS 0 Alo CITY/TOWN G <br /> Owner s dame e <br /> Phone <br /> Address ,� d <br /> Contractor"s Name <br /> Licensed Phone e-1 gda <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOr4 INSUMICE' ON FILE WITH-SJLHD? <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ RECONDITION DESTRUCTION <br /> WELL CHLORINATION [] WELL ABANDONMENT OTHER (, f-193— o ' <br /> PUMP INSTALLATION M PUMP REPAIR❑,.. . PUMP REPLACEMENT [ �` <br /> H <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP SALFIELD CESSP- OL/SEEPAGE PI OTHER p ' <br /> PROPERTY LINE - PRIVATE D MESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF-WELL <br /> _Industrial CONSTRUCTION SPECIFICATIONS �► # <br /> .Domestic/privatei� Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing r <br /> 112— <br /> Domestic/public jI Driven Gauge of Casing <br /> rri pati on !! <br /> Gravel Pack ;Depth of Grout Sea <br /> Cathodic Protection _ r <br /> -.,— 2isposal. _� U Othery 'Type of Grout <br /> Geophysical `other Information <br /> ' .,'Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor •. E, <br /> Type of 'Pump _ <br /> PUMP REPLACEMENT: H.P. <br /> []State Work Done <br /> PUMP REPAIR: <br /> OState Work"iDone <br /> DESTRUCTION OF WELL: Well Diameter : ' <br /> Describe Materl-al and Procedure Approximate Depth 7 <br /> I hereby certify that I haveprepared?-this <br /> with San Joaquin County Ordinnces , S: ateLaws-, and?Ruleson aand Regulatthe �onsrk woflthe Sanbe eJaaquinin �Loca'le <br /> F#ealth �Di`strict:""'Homo owner or licensed agent's signature certifies the following: <br /> "I certify that in thelperformance of the work for which this permit is issued, I shall" <br /> not employ any person-lin such manner as to become subject to Workman's Compensation <br /> laws of California, " i <br /> I WILL CALL FOR A GR UT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> i <br /> iIGNED TITLE: <br /> D W PL T N ON REVERSE DATE: 2 <br />'HASE I F R E JSL ONLY - <br /> IPPLICATION ACCEPTED BY <br /> rDDITIONAL COMMENTS: DATE <br /> PHASE Ii GROUT INSPECTION <br /> NSPECTION BYPHAS I L INSPECTION <br /> DATE INSPECTIONB I <br /> H 14 26 Rev, 9/78 DATE-S-/4 <br />� I 9/78 2M 1 <br />