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SAN JOAQUIN LOCAL�HEALTH DISFRIC1 <br /> FOR FICE USE: 1601- E. Hazelton Aye. , :Stockton, CA 95205 Permit No. /2�- <br /> Telephone: (209)•466-6781, <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> / <br /> This Permit: Ex` ir ' 1 Year From Date `Tssued <br /> Complete In Trip I icate <br /> lApplication is hereby made to the San Joaquin Local . Health Di-strict .f;o.r a permit to construct <br /> ' and/or install the work herein described. This .application is made -in compliance with ,San. . . <br /> doapuin County Ordinance ado. X1862 and-the Rules and_ Regu.l.ations •of the San Joaquin Local Health <br /> 4 District. <br /> EXACT STREET ADDRESS t1/S �' CITY/TOWN <br /> Owner' s Name Phone <br /> k I\ City o� <br /> Address <br /> Contractor' s Name s Licensees Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION IPJSURAINCE Oil FILE WITH SJLHD? E NO <br /> STYPE OF WORK (Check) : NEW WELL'' DEEPEN ❑ . RECONDITION Q DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER❑ <br /> PUMP INSTALLATION)g PUMP REPAIR❑ PUMP REPLACEMENT <br /> rDISTANCE TO NEAREST: SEPTIC TANK ,3 S SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL F..IELD ! CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -,PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL c <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tools Dia. of Well Excavation_ /fit t <br /> _Domestic/private Drilled Dia. of Well Casing Domestic/public Driven,,., Gauge of Casing <br /> Irrigation Gravel Pack-, Depth of Grout Seal <br /> Cathodic Protection _ Rotary ' ' •t,� Type of Grout <br /> Disposal € 1 Other C7 Other Information <br /> Geophysical/a, Surface Seal Insta led b b res <br /> PUMP INSTALLATION: Contractor `' <br /> : . Type of Pump H• . <br /> PUMP REPLACEMENT: - State Work Done <br /> PUMP REPAIR:. �.r ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter �` Approximate Depth <br /> , Describe Materia and Proce ure� .�, <br /> f i � _ <br /> FI hereby certify that 1,'have prepared t is application and. that the work will be done in accordant <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> F Heal th-Di.stri ct..—Home-oOner--o-r.1 y•censed-agent•'-s- s i-q nature--certifies the--fol 1 owi ng <br /> "I certify that in wt:hd performance of the� work.fbr 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 CALL FOR A GROUT NSPECTIO PRI R ROUTING AND A FINAL INSPECTION. <br /> , SIGNED TITLE: DATE:—v4z ,_f <br /> = DR PL L N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> [ PHASE I DATE 11479 <br /> (APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT- INSPECTION PHASE III FINAL INSPECTION <br /> :INSPECTION BY DATE INSPECTION BY 0 DATE <br /> FM Id9A�P v 1�-77 s .�ir�j�„1 2- °'^ 1'/78 2M <br />