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'i SAN JOAQUIN LOCAL .HEALTH DISTRICT Permit <br /> Stockton, CA 95205 <br /> F'ICE USE: 1601 E. Hazelton Ave(2D9 466-6781 <br /> Telephone: . ) Date Issued �- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> ire's 1 Year From Date �Tss-ued °^ �r�" ` <br /> ThisrPermit Ex <br /> # CompI ete> In Triplicate <br /> made to the San Joaquin Local Health District made irircompliancea permit twithnSanuct . <br /> Application is hereby li.cation 1 <br /> and/or install the-work herein described. <br /> e hyo: 1862 and the :Rules and Regulations of the Sane:Joaquin ,Local Health <br /> ,;oaquin County-ordinance c <br /> DiStr�ct. CITY/T.OWN ; <br /> EXACT STREET ADDRESS � . / � . Phone <br /> l Owner' s Name 7tz jfCity <br />( Address . License# Phone <br /> Contractor' s Name <br /> . . NO <br /> IS CERTIFICATE OF WORKMAN S COMPENSATIO'l'INSURA?10E 04 FILE WITH SJLHD? Y <br /> ` DEEPEN ❑ RECONDITION C3 — DESTRUCTION[] <br /> TLE OF WORK (Check) : NEW WELL❑ WELL ABANDONMENT 0 OTHER❑ <br /> WELL CHLORINATION C3REPAIR❑ PUMP REPLACEMENT <br /> l PUMP INSTALLATION N PUMP <br /> r <br /> SEWER LINES, _ PIT PRIVY OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT-- <br /> SEWAGE DISPOSAL FIELD PUBLIC D MESTIC WELL <br /> # PROPERTY LINE -. PRIVAT D ESTIC WELL ---- <br /> yTYPE OF WELL : . CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Cable Tool Dia.F'Of Well Excavation <br /> industrial -----Drilled Dia. of. Well Casing <br /> I 'Domestic/private Gauge of Casing <br /> k Domestic/public ©riven <br /> Gravel Pack Depth of Grout Seal <br /> Irrigation Rotary Type of Grout <br /> Protection Other Information <br /> Disposal Other <br /> Surface Seal Installed bLj <br /> Geophysical r <br /> PUMP INSTALLATION: Contractor H. . <br /> Type' of Pump <br /> I ' <br /> IIPUMP REPLACEMENT: ❑S.tate Work Done <br /> []State Work Done <br /> PUMP R Approximate=.Depth <br /> } ESTRUCter <br /> TION OF WELL: DescribemMateria and Procedure <br /> this application and that the work will be done in accorda <br /> , I hereby certify that I have prepared <br /> !with San Joaquin County Ordinances , State -Laws , 'and Rules and Regulations of the San Joaquin oc <br /> , Health District. Home owner or licenseod thenworksignature <br /> whichcertifies <br /> permiteisoissued9� I shall <br /> "I certify that .in the performance <br /> not employ any person in such manner as to become subject to Workman' s Compensation <br /> laws of California." <br /> iI WILL CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND A FINAL. INECTION• <br /> SPDATE. <br /> TITLE <br /> 'SIGNED t DR W PLOT PL N M REVERSE S• DE <br /> F R DEPARTMENT USE ONLY / <br /> PHASE I t DATE l �7`V <br /> APPLICATION ACCEPTED BY �! <br /> ADDITIONAL COMMENTS: PHASE I FINA INSPECTIO <br /> PHASE II GROUT INSPECTION DAT <br /> INSPECTION BY DATE INSPECTION BY <br /> _ 7 78 <br /> _ _ <br />