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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE; 1601 'E Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone; (209) 466-6181 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued MAR 15 1978 <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 made irr compliance with Sane " <br /> Joaquin County Ordinance No.: 1862 and the ,Rules .and Regulations of the San -Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRE5S15X S' 42 3 CITY/TOWN <br /> Owner's Name Phone <br /> - i <br /> Address City - <br /> Contractor's Name Licens '' Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO.I INSURANCE ON FILE WITH SJLHD? YES 4---'NO <br /> TYPE OF WORK (Check) : NEW WELL C DEEPEN CYC RECONDITION 21' DESTRUCTION ] <br /> WELL CHLORINATION ga�— WELL ABANDONMENT p OTHER 0 ' <br /> PUMP INSTALLATION [ - PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK ej� EWER LINES SPIT-zPRIVYa <br /> SEWAGE DISPOSAL_ FIELD CESSPOOL/SEEPAGE—PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC +WELL A- `R PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL y '•'CONSTRUCTION SPECIFICATIONS <br /> ndustri AT— able Tool ' Dia, of Well Excavation <br /> Domestic/private Drilled Di a—of-Wel 1—C8si ng �s <br /> Domestic/public Driven Gauge of Casing <br /> 12 <br /> &:; Irrigation Gravel Pack Depth of Grout Seal- <br />-Cathodic Protection Rotary Type of Grout - <br /> Disposal Other Other Informatio_ ' <br /> - Geophysical Surface Seal Installed b <br /> r i <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump H . , <br /> PUMP REPLACEMENT: rj State Work Done <br /> PUMR_-REPAIR: Q State Work Done i <br /> DEST,Ut�TION 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 /> pith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> lealth District. Home owner or licensed age ntIs 'signature certifies 'the `following: <br /> "I certify that in the performance of the work: for which this permW is issued, I shall #A- <br /> not -employ any person in such manner as to become ;subject to Workman`s ,Compen"sation <br /> laws of California. " ' <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION.+ <br />;IGNED TITLE: <br /> �_/7A 7 <br /> (DRAW PLOT PL N E ON REVS SSIDE '. t DATE: <br />'HASE I FOR DEPARTMENT USE ONLY 1 <br /> IPPLICATION ACCEPTED BY ' DATE <br /> 0 DITIONAL COMMENTS : ` <br /> PHAS II GROUT INSPEGTIO _ �;- PHASE I, FI L INSPECTION <br /> NSPECTION BY —DATE INS-PECTION. BY - DATE <br /> �. <br /> H 142f; Rat. 19-1 <br />