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N JOAQUIN LOCAL HEALTH DISTRIC . - <br /> w EQR OFFICE USE : 1601 E , Hazelton Ave . , Stockton , CA 95205 Permit No .. 22 7 <br /> Telephone : ( 209_) 466 - 678I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued L9- <br /> ( Complete In Triplicate ) <br /> 4vplication is hereby made"-Oto the San Joaquin Local Health District for a permit to construct <br /> and/ or installrthe • 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 /> ) istrict , <br /> EXACT STREET - ADORES S �' fioftCo CITY/TOWNSi/MkMAJ <br /> )wner ' s Name �/' "T nJ .A9'Ou N N Phone 4E <br /> <' <br /> lddress 17 = to St3(J CQ City S �CfC { �7 <br /> : ontractor ' s Name icense# 7, Phone <br /> ��f2—���� <br /> IS CERTIFICATE OF WORKIiAN ' S COMPENSATION INSURANCE ON FILE WITH SJLHO? YES NO <br /> TYPE OF WORK ( Check ) : NEW WELLI+F DEEPEN" ❑ RECONDITION Q. DESTRUCTION [j <br /> WELL, CHLORINATION 0 WELL ABANDONMENT p OTHER 0 <br /> tPUMP NSTALLATION ❑ PUMP REPAIRIO PUMP REPLACEMENT Q <br /> ) ISTANCE TO NEAREST : ' SEPTIC" kTANK��� SEWER NES PIT PRIVY <br /> SEWAGE DISPOSAL f. IELO 7 CESSPOOL/ E f�E PIT ---" OTHER -= y <br /> PROPERTY LINeaF7 RIVATE DOMESTIC WCL ' PUBLIC DOMESTIC WELLe: G <br /> INTENDED USE at TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Andustrial ' ;, —C-ab"l-e Tool Dia . oaf Well Excavation /0 ' <br /> Domestic/ private Drilled t Dia . ,of Well Casing <br /> Domestic/ pubic + Driven Gauge of Casing "by : <br /> Irrigation ii avel Pack Depth of Grout SeCathodic Proteotlon ; Mary Type of Grout 3Disposal 4Other , Other Information <br /> GeophysicalSurface Seal Inst <br /> PUMP INSTALLATION : Contractor SRd' I, CJ Z4 701 <br /> y R , Type .of Pump - H . P . / rf <br /> PUMP REPLACEME V:- r] State Work Done re <br /> PUMP REPAIJ3.;:. ;e. [] State Work Done <br /> [DESTRUCTION OF?WELL : . -,%,Well ; Diameter Approximate Depth <br /> Describe Material and Procedure <br /> J <br /> I hereby certify that I have prepared this application and that the workxwill . be, done • in accords <br /> Nit'h •�San Joaquin County Ordinances , State Laws , and Rules and Regulationslofefie , San Joaquin Loc <br /> Heath District : Home owner or licensed agent ' s signature certifies the following : <br /> " " T,;certify that in the performance of the work for which this permit is issued , I shall <br /> nol: employ any person in such manner as to become subject to Workman ' s Compensation <br /> laws of California . " , <br /> IWItL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION . i <br /> SIGNED: £' <br /> l _ _ _ _. .. TITLE : vv, _ _ . DATE : (,-7-0 9 <br /> DR W PLOT PL N ON REVERSE SIDrl <br /> -- <br /> . . . <br /> -,,r, FOR �DEPARTMENT USE ONLY <br /> PHASE IA <br /> TION ACCEPTED B r r' <br /> APPLICATION 2 `y <br /> ADDITIONAL COMMENTS : a " <br /> PHASE II GROUT., INSPECTION7o27 <br /> — PHAS II INAL ON <br /> INSPECTION BY DATE_ PECTION BY / ' SLH 14 26 Rev . ,9/ 78 _ , /f� 77 2t <br />