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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: . 1601 E'." Hazelton Ave. , Stockton, CA 95205 Permit No. .� 8" <br /> Telephone: (209) 466-6781 <br /> APPLICATION EOR WELL CONSTRUCTION OR. PUMP' PERMIT <br /> Date Issued . �- 7 <br /> (complete <br /> . In Triplicate) <br /> r <br /> : p tate) <br /> Application is hereby made to the San, JoaquintLocal Health District fora permit to construct <br /> and/or -install the work herein described:: This appl'i.cation is made in compliance with San <br /> Joaquin County Ordinance No. 1862 an tithe Rules and Regulations f the San Joaquin Local Health 1 <br /> District. t' J* D6� �- o�o -- !`'�� <br /> EXACT STREET ADDRESS d StA Ro Ci,TY/TOWN �'`�'nvf �1`��� <br /> nl <br /> ,i <br /> Owner's Name �' Phone . µ. <br /> Address v. �jo t <br /> City In1q <br /> Contractors Name ogsLicense# 77 Phone <br /> IiMTS CERTIFICATE'-OF,WO.RKt_(ANIS-:.COl�"-P-ENSATION-,�.I.NSURANCE--ON—R-F-ILE WI-TH-SJLHD?�. YES °fes- <br /> TYPE` OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION CJ. . <br /> WELL CHLORINATION 0� /4ELL ABANDONMENT ® OTHER 0 <br /> PUMP INSTALLATION LIr PUMP REPAIR C7-.-' . PUMP REPLACEMENT <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK �7 SEWER LINES 1)0 / PIT PRIVY T <br /> SEWAGE DISP SC! A�FIELp o � CESSP OL/S, EPAGE �— OTHER <br /> PROPERTY LINEa&bPRIVATE D MESTIC WELL PUBLI —90-MESTIC E13 L�� <br /> 3 INTENDED USE- iT OF-WELL... CONSTRUCTION SPECIFICATIONS �1 <br /> Industrial Cables Dia. of dell Excavation pl <br /> . �Domestic/private Drilled Dia. of Well Casing <br /> CIO <br /> _Domestic/public Driven Gauge of Casing wg11 , <br /> Irrigation.. _ Gravel Pack Depth of Grout. Sea <br /> �„�Cathodic Protection so <br /> Rotary Type .of Grout <br /> ._Disposal <br /> . .Geophysical Other Other Information <br /> -------- <br /> Surface Seal Inst ed <br /> PUMP INSTALLATION: Contractor , F <br /> c <br /> Type of Pump <br /> PUMP REPLACEMENT: 'Q State`Work Done <br />-m2_ REPAIR - <br /> _a _ O,StateWo.r.k—D.one. _= <br /> DESTRUCTION OF WELL: Wel ] Diameter f <br /> Describe Materia and Procedure 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 6r 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 <br /> laws of California. " 4 <br /> I WILL FOR OUT IN ECTION PRIOR TO GROUTING ANDFINAL INSPECTION. <br /> SIGNED TITLE: DATE: [agh <br /> 61 <br /> DR W PL L N ON REVERSE SIDE <br /> N USE ONLY <br />'RASE I ?UR DEPARTMENT . <br /> PPLI ATION ACCEPTED "BY <br /> ADDITIONAL COMMENTS: DATE_k— Z? <br /> PHASE .II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> fYSPECTION BY DATE INSPECTION BY �► <br />:H 14 26 Rev. 9/78 DATE <br />-- �. 7A OV <br />