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_V/- SAN JORQUI N LOCAL HEALTH U151 K1 C;1 <br /> FFICE USE: 1601 E. Hazelton .Ave. ,. Stockton, CA 95205 Permit No. ?Y-77T <br /> ---� Telepponel--(2n) 4666781 -- <br /> APPLICATION FOR �WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires . l Year From Date Issued <br /> AH Complete In Triplicate <br /> . Y i <br /> Aoplication i's hereby made to the San Joaquin Local Health District for a -permit to'construct <br /> and/or,�insta,ll the work- herein described. This application is made in compliance with San <br /> Joaquin County-Ordainahg- No. 1862 and t e RLdes and, Re ulations of.the San Joaquin Local Health <br /> C,istrict. = 32 <br /> EXACT 'STX EET'hbDRE'SS ' ` CITY/TOWN n, <br /> Owner's 'Name'°� Phone 34/_ a& <br /> Address City <br /> Contractor'xs Name I) -A.0 jo,-K _ � License# Phone ' (, (?-a 2i-:�;-C? <br /> S CERTiF•I.GA OF WORKMAN'S COMPENSATIO"1 IINSURAONCE ON FILE WITH SJLHD? YES NO <br /> PE. OF„�ORK- Check) : NEW WELLS DEEPEN ❑ RECONDITION Q - ""DESTRUCTION'[] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> f <br /> I-STANCE...TO._!EARE-S-T SEPTIC TANK�ne, SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ,E <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL - <br /> INTENDED-USE - <br /> ELLINTENDED_USE _ _ --- - — —.TYPE OF WELL . . + CONSTRUCTION SPECIFICATIONS <br /> Industrial - -- w --Cabl-e Tool-•--- yD -a,—of-Well -Excavation <br />_;e,�Domestic/private Drilled Dia. of Well Casing Domestic/public '! Driven Gauge of Casing <br /> Irrigation i Gravel Packs Depth of Grout Seal •rte ` _ <br /> Cathodic Protection Rotary . Type of Grout ,. - <br /> Disposal g Other Other Information <br /> Geophysical I� Surface Seal Instal= ed b <br /> PUMP INSTALLATION: ContractorA <br /> Type of PumpAUa:1mr4AA'XAkQ <br /> H.P. ” <br /> 1. <br /> PUMP REPLACEMENT: Q State Work Done } <br /> PUMP REPAIR: EState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and 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 /> Health Di s-tri ct: -Home owner or 'licensed agent's s-i gni Lure 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." i! <br /> I WILL CALL FOR A GROUT -INSP CTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: !r 7. <br /> DRAW PETT-TE N ON 'REVER5 SIDE <br /> FOR DEPARTMENT USE'ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 5 26, 176 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY f DATEINSPECTION BY r DATE .d <br /> H„1426 Rev. I2-77 <br /> 'off `.(? x1/'78 2M <br />