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. .'AN JOAQUIN LOCAL HEALTH D STRICTy <br /> FOR . FFI.CE`USE: 1601t, Hazelton Ave. , Stockton, CA 95205 Permit No. 7� <br /> r t Telephone: (209) 4666781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issuedy 7 <br /> This Permit Expires 1-Year From Date Issued <br /> Complete In Trip icate <br />`AO-Plication 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 ,in compliance with San <br /> Joaquin'., County Ordinance No: ',1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District . <br /> EXACT' STREET ADDRESS-2. !S_0 s1�1 / L� �E�4, CITY/TOWN_d6,1 '1110 Com , <br /> Owner's Name Cet_boow Phone <br /> Address '70 1J, City <br /> Contractor's Name� 5 ��lrlT� �ytcJ /J�P�GC� cen"s # 3SZ $T'Pho <br /> IS CERTIFICATE OF WORKMAN'S` COMPENSATIO"i.-ItISU,RA�:ICE ON FILE WITH SJLHD? YES 3 6$ NO <br /> TYPE OF WORK (Check). NEW WELXR <br /> DEEPEN ❑-"""RCCONDITION ❑ DESTRUCTION C)WELL C'HLNATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT <br /> DIS-T—ANC':E-1.O-NEA-R-EST: xSEPTI-C-TANK100 SEWER LINES .100 PIT PRIVY Ic <br /> SEWAGE- DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ,_ <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION'' PEC-IFICATI-ONS <br /> Industrial Cable Tool Dia. of Well Excavation iz!l �? <br /> X Domestic/private Drilleed Dia of Well Casing r� <br /> �Dpmes'ti c/publ i c Driven Gauge of Cas i rid_ <br />'F. Irrigation Gravel Pack Depth of Grout Seal 1 <br /> Cathodic Protection Rotary Type 'of Grout =P&)g C;gAUK: <br /> Disposal Other Other Information i <br /> Geophysical Surface Seal Installed b 0cQNEC__' , <br /> PUMP INSTALLATION: Contractor <br /> F Type of Pump H.P;- __ <br />"PUMP REPLACEMENT: [7 State Work Done <br /> PUMP REPAIR: ❑State Work Done - <br /> DESTRUCTION OF WELL: Well DiameterApproximate Depth <br /> Describe Materia an rocedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br />��rr��th San Joaquin County Ordinances, State Laws; and Rules and Regulations.: of the San Joaquin Local <br /> wealth 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 <br /> laws of California." I <br /> .I WILL CALL OR A GROUT' INSPE TIN PRIOR TO GROUTING ANDA FINAL I INSPECTION. <br /> f i . ,ad�, <br /> SIGNED T-ITL-E: ai4 -� DATg � S <br /> Z- ', <br /> 78. <br /> i4WAW -PtDT -PLT-4--ON-REVERSE SI.DE) <br /> FOR DEPARTMENT USE ONLY -PHASE I <br /> APPLICATION ACCEPTED BY _ -• -F- -DATE' <br />_ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSRtCTION <br /> NSPET,iON. BY DATE INSPECTIONBY DATE <br /> ki <br />,FH 1 4 7 Filr 69-'77- <br />