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SAN JUAQUIN LUCAL. HLALIH DISIRICt <br /> OFFICE USE: I60I E Hazelton Ave. , Stockton, CA 9�}f Permit No. -7/3�o <br /> �Felephone:. (209) '466-6.781 <br /> APPLICATION FOP WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires T Year ,From Date Issued <br /> Complete <br /> In Tr"•i.pl i tate <br /> 1 ication is hereby made to the San Joaquin Ucal, He,a1 th, District, for a permit to ,construct. <br /> �,/or install :the-work herein described. This application is made in compliance with Sats. <br /> )aquin County..OrdiMance No. i186.21and the Rules and- Regulations of the San Joaquin -Local Health <br /> i,-trict. <br /> %.*CT STREET ADDRESS' ,Z-%5/ �SD fhfl_�S CI-TY/TOWN_tf <br /> %per's Name ir�J �7 ''. N' ? S ! _-- - - Phone 3 4 <br /> re s s S l 1 So ta/—S —L, i ty f3 C19 r��G <br /> 3ntractor' s Name [� r � �/� l�/`�� Js ?LL,,rICC', Li cense# � .37Q—1 .Phone <br /> ,. <br /> CERTIFICATE OF WORrIMAil'S CO%iPEtISATIO'€ INSURANCE ON FILE WITH SJLHD? YES >� NO <br /> YPE OF WORK (Check) : NEW WELLtZ DEEPEN ❑ RECONDITION ® DESTRUCTION❑ <br /> WELL CHLORINATION C# WELL ABANDONMENT 0 OTHER 0 9 <br /> '-' PUMP INSTALLATION 0 PUMP REPAIR C7 PUMP REPLACEMENT ❑ S <br /> Y: <br /> TA NCE TO NEAREST: SEPTIC TAN KC L5- SEWER LINES SPIT PRIVY <br /> ►. SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINES RIVATE DOMESTIC WELL -PUBLIC DOMESTIC WELL— ----- <br /> INTENDED <br /> ----INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> „Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing c <br /> Irrigation Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection Rotary Type of Grout S 4 « <br /> Disposal Other Other Information <br /> .,, Geophysical Surface Seal Installed by: <br /> UMP INSTALLATION: Contractor <br /> 1 . Type of Pump H.P. <br /> i41P R£PLACEMCNT: Q State Work Done <br /> 11HP REPAIR: ❑State Work Done <br /> L�TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> +-riereby certify that I ;nave prepared this application and that the work will be done in accordant <br /> ith San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Local <br /> filth District. Home owner or licensed agent's signature certifies the following: <br /> u "I certify that in the performance of the work for which this permit is issued, I shall -A Xrc. <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California." <br /> 4LL CAL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNEDTITLE: � � DATE: <br /> DRAW PLOT PLTNT ON REVERSE SIDE <br /> �.. FOR DEPARTMENT USE ONLY <br /> -HASE I <br /> 7OLICATION ACCEPTED BY DATE <br /> yaITIONAL COMMENTS : <br /> PHASE II G OUT INSPECTION PHASE III FINAL INSPECTION <br /> "SPECTION BY DATE �- INSPECTION BY Tom . DATE s, <br /> 1 /78 2M <br /> 1d I a7F Ppv 19-77 <br />