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�EANHaz0eRton Ave. , <br /> HEALTH DISTR <br /> FFICE USE: 16 . <br /> e. , .Stockton, CA %205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued � 7-►�� <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 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 ADDRESSY9 A4; <br /> . . <br /> Owner's dame ,v�ITY/TOWN <br /> / S Phone 1- �9"oy' <br /> Address . <br /> Contractor's Name Ci al <br /> r : License Phones <br /> IS CERTIFICATE OF WORKIMAN-S CO"IPENSATION INSURANCE ON FILE WITH SJLHD? YE <br /> S O <br /> 'TYPE OF WORK (Check) : NEW WELL C� . DEEPEN�I' RECONDITION [� DESTRUCTION( - _ <br /> a. <br /> WELL..CHLORINATION j� WELL ABANDONMENT fl OTHER j� <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [ <br /> )ISTANCE TO NEAREST: SEPTIC TANK- _ SEWER LINES,SO. OTHER <br /> PIT PRIVY <br /> SEWAGE DISPOSAL� FIELD CESSP O!/SEEPAGE PI7� <br /> PROPERTY LINLe4+PRIVATE DOMESTIC WELL .#-PUBLIC OMESTICWELL -- <br /> c <br /> INTENDED USE TYPE OF WELL - <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> __.,__Domestic Cable Tool Dia. of We]l Excavation <br /> /private Drilled Dia. <br /> Casing f Well <br /> omestic/public - auge Casing <br /> Driven G •- o� , <br /> _` Irrigation Gravel Pack Depth of Grout S <br /> Cathodic Protection Rotary <br /> isposal ea <br /> Other Type of Grout <br /> Geophysical Other Information <br /> Surface Seal Insta ed b ' <br />` JMP INSTALLATION: Contractor �~ <br /> � Type of Pump H.P. <br /> !MP REPLACEMENT: Q State'Work Done <br /> IMP REPAIR: <br /> ❑State_Work Done <br /> :STRUCTION OF WELL; Well Diameter , <br /> Describe Mate, IV and Proce ure Approximate Depth <br /> hereby certify that- I have prepared this'.application and that <br /> the work th San Joaquin County Ordinances , State Laws and Rules and Regulations woflthe Sanbe eJon Joaquin <br /> alth District, Home owner or licensed agent's signature certifies the following: <br /> again Local <br /> "I certify that in the performance of the work -forg <br /> not employ any person in such manner as to become subject Workman's issued, I shall <br /> laws of California. Compensation <br /> JILL CALL FOR A G UT NSP C ON PRIOR TO' GROUTI <br /> iNED NG AND A FINAL INSPECTION. i . <br /> I D TITLE: DATE:,' <br /> L ON REVE S SIDE <br /> PLwf �� y <br /> ,SE I FOR DEPARTMENT USE ONLY <br /> 'LICATION ACCEPTED BY / <br /> 'ITIONAL COMMENTS: DATE <br /> PHA II GROUT INSPECTION <br /> RECTION BY DATE PHA E I INAL INSPECTION <br /> 14 26 Rev. 9/78 INSPECTION BY DATE <br /> --Q-1 7AI-_ ou <br />