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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFIC E USE: 1601 E. Hazelton Ave:,, <br /> Stockton, CA 95205 Rermit.No. <br /> _z�l�_ <br /> Telephone: (20 .466-6781 <br /> 4,66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ <br /> (tamp l ete In Tri p'A cate' <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. 9 I` A <br /> EXACV STREET. ADDRESS <br /> 3 d CITY/TOW <br /> Owner's Name f., Phone <br /> Address M <br /> -City <br /> Contractor's Nam L`i. ens,e 193-?AIRon ' <br /> � . - 76 <br /> 1 L CERTIFICATE •OFWORKt1AN'S CO"jPEN TI d INSURA^ICE ON FILE WITH SJLHD? YES 0 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEOEN [j RECONDITION DESTRUCTION{ <br /> WELL CHLORINATION WELL ABANDONMENT 0 OTHER rj <br /> PUMP INSTALLATION Ca PUMP REPAIR 0 PUMP REPLACEMENT <br /> 'DISTANCE TO NEAREST: - SEPTIC TANK SEWER LINES . ._ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP L/SEEPAGE PIT OTHER <br /> PROPERTY LINE' - PRIVATE DOMESTIC, WELL .— PUBLIC D MESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial ICable Tool F Dia. of Well i=xcavation <br /> Domestic/private F Drilled Dia, of Well Casing <br /> ,Domestic/public Driven <br /> Irri ation Gauge of Casing <br /> g l Gravel Pack Depth of Grout Sea <br /> Cathodic Protection I Rotary T <br /> Disposal r Other ,, ype-,of Grout - --.� <br /> Geophysical Other Information <br /> PUMP INSTALLATION: Contractor Surface Seal Insta ed b <br /> Type of Pump . / H.P. . <br /> PUMP REPLACEMENT: State Work Done ~ <br /> PUMP QState' Work Done <br /> DLSTRUCTION OF WELL: Well Diameter <br /> Describe Materia ano Procedure ;4 ` Approximate Depth` <br /> I hereby certify that I have prepared this application and that the..,wark. wi.Tl be don <br /> Kith San Joaquin County Ordinances , State Laws, and Rules. and Regulations of a in accordance <br /> ieal'th District. Home owner or licensed agent's signature certifies the followen:gh Joaquin Local <br /> "I certify that in •the performance of the work for which this permit. is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation t <br /> laws of California. <br /> WILL CA FORA GROUT INS T N I TO GROUTI <br />;IGN NG ANDA FINAL INSPECTION. <br /> TLE: DATE: <br /> L L REVERSE SI E <br /> HASE .I FOR DE RT "NT USE Y <br /> Pp G ATI ON ACCEPTED BY , ,/ <br /> DDITIONAL COMMENTS: A <br /> PHASE II GROUT INSPECTION iM r 4 <br /> qSPECTION BY DATE jl PH E INSPECTION <br /> l.rl4 26�.Rev.,9/78 INSPECTION BY DATE �; <br />