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t <br /> SAN JOAQUIN IPOCAL HEALTH DISTRICT <br /> P�.,Q�FFICE USE: 1601 E. Hazelton -ave. , Stockton, CA 95,205 Permit No. <br /> Telephone,-.. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION 0R­PUMP PERMIT Date Issued r <br /> 'a <br /> (Coinplete.•In Triplicate) x, <br /> Application is hereby madeto 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 _ CITY/TOWN' .00l. R <br /> Owner's Name Pr:�,�,,rf y <br /> Phone y'y& <br /> Address N ¢G, S� 11 City_ �c <br /> Contractor's Name Orr ,'rev t License#,2GS96f Phane /r. 7 + <br /> IS CERTIFICATE OF WORKMA141S COMPENSATION INSURANCE-ON FILE'WITH-SJLHD? YES ,L N0 T <br /> TYPE OF WORK (Check):' NEW WELL M DEEPEN ❑ RECONDITION ® DESTRUCTION[�r_ <br /> a WELL CHLORINATION ❑ WELL ABANDONMENT ® OTHER El <br /> PUMP INSTALLATION M PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP- OL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC 'WELL <br /> -- <br /> INTENDED..USE TYPE OF-WELL., CONSTRUCTION SPECIFICATIONS J <br /> f Industrial {' ' <br /> � Cable Tool Dia: of Well Excavation <br /> Domestic/private , Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation . , t Gravel Pack Depth of Grout Sea <br /> Cathodic Protection k Rotary Type of. Grout <br /> Disposal p Other _Y Other Information <br /> Geophysical „ Surface Seal Insta ed- - r — <br /> PUMP INSTALLATION: . _ Contractor. <br /> Type Of Pump <br /> PUMP REPLACEMENT: ❑State 'Work l Done <br /> PUMP .REPAIR: ❑State ;Work Done <br /> DESTRUCTION OF WELL: Well Diameter Appr imate Depth Oo <br />}� Describe Materia an race ure ' <br /> l <br /> fI hereby certify that I have prepared this application and that the .work will be done in' accordanc <br /> with San Joaquin County Ordinances - State Laws , and Rules and Regulations .of .the San Joaquin-Local <br /> rHealth District. Home owner-rlor 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. <br /> i WILL CA OR A G T I ECT PR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> RAW, PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT; USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .,r, av DATE Z5Z�l <br />.ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY - DATE INSPECTION BY-; DATE <br /> -EH 14 26 Rev. 9/78 p a�-r� g/7$: :`= 2 <br />