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t SAN JOAQUIN LOCAL HEALTH-DISTTRICT "� <br /> FFII.CE USE: 1601 E. Hazelton Ave. , Stockton,,,,/CA 95205 Permit No. ��-62,z <br /> Telephone: (209) 46616781 <br /> 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> ' 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 mach in compliance with/San . <br /> ,_oaQuin County Ordinance °aa . 1862 and the Rules -and Regulations .of ,the San Joaquin Local Health f <br /> '','iStr'Ct r , <br /> V. <br /> 41 <br /> EXACT STREET ADDRESS G ZZ~ of , )rtITY/TOWN L� 9 <br /> Owners Name .LL ,, Phone <br /> Address / ~V1 <br /> k 1TC i ty � . <br /> Contractor's Name1Li censeA2 0 shone = / .l 2 <br /> �;. <br /> Pj'+"'INSURAtae ^!CE ONFILE WITH--SJLHD?`-- YES__. <br /> ; <br /> IS CERTIFICATE OF WORKMAN'S COP1PErISATIO ``ANO, '! <br /> TES­ <br />, TYPE OF WORK (Check) : NEW WELLCi DEEPEN CJ RECONDITION <br /> ❑„ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT.❑ OTHER❑ � �' ; <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ t^�,PUMP -REP-LACEML,N Q <br /> DISTANCE TO NEAREST: SEPTIC TAN K,41g9W,SEWER LINES PIT PRIVY f` <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGEhPIT_,L r•OTHER ' <br /> PROPERTY LINE&ZERIVATE DOMESTIC WELL -- PUBLIC DOMESTI(!�WELL <br /> INTENDED USE TYPE OF WELL ,CONSTRUCTION SPEC'ICATIONS <br />' Industrial ° Cable Tool Dia. of Well Excavat-iv-n== - ;�� ` <br /> __�__�Domesti c/private -—Drilled Dia. ofIlWel l Cas i n <br /> Domestic - 9 �r-- <br /> /public Driven Gauge of C.a,s ng - <br /> I rri ati on'// b ,-- <br /> -�_ 9Gravel Pack Depth �o,f�.�rout Seal �-0 <br /> Cathodic Pfotecti on _,Rotary <br /> Ty <br /> `�of"Greut <br />' x Dis osal <br /> P ; Other Other Information <br /> Geophy�i.cal Surface Seal. Installed b : <br />� PUMPINSTALLATION: Contractor . , <br /> Type of Pump N.P. <br /> PUMP RLPLACEMENT: State Work Done .k„ <br /> PUMP,,REPAIR: ❑State Work"Done J s <br />,DESTRUCTION OF WELL: Well Diameter <br /> Describe Materia and Proce ure Approximate Depth <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 District. . Home owner or licensed agent' s signature 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 s <br /> laws of California. ' <br />.I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />'SIGNED ke <br /> TITLE: DATE: , <br /> (DRAW PLOT PLN ON REVERSE—SIDE) # <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED 'BY- _ . - DATE__ /77? <br /> ADDITIONAL COMMENTS : <br /> PH E II;`-GROUT:�,INSPECTION <br /> PHASE III FINAL INSPECTION <br />'INSPECTION BY - DATE INSPECTION BY DATE Q� <br /> „� 142A Rpy_ 19-77 <br />