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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> PEKE USE: 1601 -E. Hazelton Ave, , Stockton, CA 95205 Permit No.7 9- �1d <br /> Telephone. (209) 466-6781 <br /> APPLICATION FORWELLCONSTRUCTION OR PUMP PERMIT Date Issued -? <br /> .(complete I'n Tri pl i ca:te). <br /> Application is hereby made to the San Joaquin Local Heal-th 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 />'EXACT STREET ADDRESS ' - <br /> v � CITY/TOWN <br /> Owner's Name C e, Phone <br /> Address <br />:Contractor's Name .t License#/93 Phone 7�Zw <br /> i, <br /> IS-CERTIFICATE OF WORKr1AN'S 0"/PENSATIO ! <br /> INSURANCE ON FILE WITH 5JLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 E ONDITION DESTRUCTION(n., <br /> WELL CHLORINATION 0WELI:�ABANDONMENT OTHER <br /> PUMP INSTALLATION Q PUMP REPAIR 0 PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC�iTANK 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 <br /> Industrial Cable Tool Dia, of Well Excavation <br />� Domestic/private A Drilled Dia. of Well Casing <br /> Domestic/public r Driven' Gauge of Casing <br /> Irrigation t Gravel,,Pack _ ' Depth of Grout Sea s <br /> Cathodic Protection i Rotary . Type of. Grout <br /> Disposal ,i -0ther Other Information <br /> Geophysical ;t - Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor ,» ` <br /> Type of Pump H. . r <br /> PUMP REPLACEMENT: Q State Work Done .. . , <br /> PUMP REPAIR: State 'Work'"Doii <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an rote ure <br /> Z 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 /> gealth District. Home owner or licensed agent's signature certifies the following: f <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ any person in sdch manner as to become subject to .Workman's Compensation - <br /> laws of California. <br /> I WILL CALL FOR A GROUT INSPECTION PRI-M TO GROUTING AND A FINAL INSPECTION. <br /> aIGNEDTITLE: f^cai DATE: /W.A 9 <br /> Phn <br /> W PLAN ON REVERSE SIDE <br /> ry <br /> ---FOR— DEPARTMENT USE ONLY <br />)HASE I ._ <br /> PPS L IC/ITION ACCEPTED BY- <br /> DATE9. V DATE ' <br /> kDDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION' PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION DATE /O-/-7 s <br />:H 14 26- Rev. 9/78 9I7R ., - 2M <br />