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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FFIEE USE: 1601. E. Hazelton Ave. Stockton., CA 95205 Permit <br /> Telephone: (209) 466-6. 781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT e Issueds�,?=?�, <br /> (complete In—Triplicate,), ° <br /> Application" is her <br /> eby made to the San Joaquin Local .Health District .f r a permit to -construct <br /> and/or install the, work herein described. This application is made.-An compliance with San ' <br /> Joaquin County Ordinance No': 1862 and the Rules and Regdlati_ons of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS <br /> CITY/TOWN <br /> Owner's Name Phone <br /> Address 110 . UL- <br /> City <br /> • Contractor's Name License# Phone <br /> IS CERTIFICATE .OF WORK"IAN'S COQ"PENSATION INSURANCE ON FILE`WITH-SJLHD? YES <br /> ,I <br /> YPE OF WORK (Check) : NEW WELL L - DEEPEN 0 RECONDITION ® DESTRUCTION[ <br /> x WELL iCHLORINATION n WELL ASANDONMENT.� OTHER 0 � <br /> PUM��( NSTALL�ATION =J_ PUMP REPAIR0- PUMP REPLACEMENT J4 <br /> DISTANCE TO mraDrvr. -- -SEP-T-1-C—THAW <br /> SEWAGE DISPOSAL IELD CESSP OL/SEEPAGE PIT OTHER, - <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE . TYPE OF-WELL., <br />' Industrial CONSTRUCTION SPECIFICATIONS <br /> — � .,. . Cable Tool. Di-a. of We'�C_EXcavatlon -ate.:_ <br /> omestic/private k Drilled Dia: of Well .Casing r <br />' .Domestic/public �- Driven - <br />. <br /> Irrigation <br /> Gauge of Casing <br /> Graver Pack --Depth-cf, Grout Sea <br /> =Cathodic' Protection Rotary CType of Grout � �.. <br /> Disposal Other Other Information <br /> ,.� <br /> , Geaphysical <br /> Surface Seal Insta e byT <br /> 'IMP INSTALLATION. . , Contractor . <br /> Type df Pump t <br /> PUMP REPLACEMENT: H.P. <br /> o State Work Done <br /> PU ' <br /> MP REPAIR: y <br /> ( State Work Done <br /> ESTRUCTIOfV�`pFnWELL� <br /> Well Diameter~ <br /> Describe-NTat ria an roce ure_—_ Approximate Depth - <br /> 4 Y -.* - - F �c-a"jl 'ti.�- -..tiai* •�-V.rte 1 <br /> I hereby certify that I have prepared this application and that tii he work will be done in accordant; <br /> with-San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaqui-n,Local,' <br /> Health District. . Home owner or licensed agent's signature certifies the following: <br /> "I certif, that ,in the erfo°rmanceo?f the work for which this permit is issued, I shall <br /> certify <br /> that <br /> employ`anyrype on pn such manner, as to become subject to Workman's Compensation I <br /> 1aws_:of Ca1i•forn a:" - - --���; } � - J -�, <br /> I WILLF- A GROU I PECTION`PRI0k, TO GROUTING AND A FIML - INSPECTION. <br /> SIGNED TITLE: DATE: <br /> -DRAW PLT 7L-FN- ON REV R D <br /> PHASE I R DEP RTMENT USE ONLY <br /> APPLICATION'ACCEPTED BY ' l 3 <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE '11 GROUT INSPECTION '.' <br /> INSPECTION BY PHASE II INAL �NETIONDATEi �/ INSPECTION BYS" ?. <br /> EH 14 26 Rev. 9/78 <br />