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� ,N JOhq .+ L-OCAL HEALTr, DISTRIX-- — — <br /> FOR OFFICE USE: 16U'"" Hazelton .Ave. , Stockton, CA 205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued -�,�0 <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. k, <br /> EXACT STREET ADDRESS�f 9 rc �ro�llo' " /l�� t�'C.T�1� CITY%TOWN ��Gy(�/d <br /> Owner's Name �h r P r Phaney� -7 <br /> Address Ci ty O < <br /> y�, �41 -,z.z <br /> Contractor' s Name j" <br /> - - ` ' �. Lic�'nse � D,Z`O�Phone <br /> IS 'CERTIFICATE OF WORK14AN'S C•O"iPFNSATION IiiSURANCE Oia FILE iWITH SJLHD? rYES NO <br /> TYPE OF WORK (Check): NEW WELLIX . DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> :WELL CHLORINATION ❑ '-WELL ABANDONMENT ❑ OTHER❑ _ <br /> -PUMP INSTALLATION ❑ :, PUMP REPAIR 0 PUMP. REP.LACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPT fti' TANK / Gf--V SEWER LINES PIT PRIVY <br /> SEWAGE;DISPOSAL FIELD-/� CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL `� PUBLIC DOMESTIC WELL <br /> INTENDED USE ��,� ,..TYPE OF WELL :} i CONSTRUCTION SPECIFICATIONS <br /> LY <br /> Industrial /Cable Toole, Dia. of Well Excavation <br /> k---Domestic/private �. -Dr,i 1led� y�� Di,a. of..Wel l Casing <br /> zz <br /> -Domestic/public •.� Dr1'ven'- Gauge of Casing. <br /> Irrigation -Gravel Pa, ., Depth•�of Grout Seal `7' <br /> Cathodic Protection Rotary- • ` w Type of Grout <br /> Disposal ; bher r;wOther Ynformation <br /> _! -,--,Sur acs Seal-Seal,.-Instal b <br /> Geop6hysical - r _� N <br /> •a,. r� <br /> PUMP INSTALLATION-:y :Contractor cJ11 =' l ` <br /> - : Type of gPump" H.P. <br /> PUMP REPLACEMENT: ❑ State Work Doag ' <br /> PUMP REPAIR: ❑State jWO.rk 'Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: MelI Diameter' <br /> Describe Material and Procedure <br /> I hereby certify that :I have prepared this application and that the �work will be SaneJoa Joaqaccouin <br /> with San Jacquie County;' Ordinances , State Laws, ani Rules,,and Regulations o� the San Jacquie L <br /> Health District. Homeowner or licensed agent' spsignatur-e--cer-tifies the following: <br /> "I tif '' that in the performance of the work for which thi1srpermit i . issued, I shall <br /> certifynot employ any persah in such manner as to become subj:qct. to Workman' s ,Compensation <br /> laws of California : <br /> I WILL CALL FOR A GROUT I SPECTION PRIOR TO GROU_tAG AND A FINAL INSPECTIONS <br /> SIGNS TITLE: e ' DATE:�� `JG� i <br /> - DRAW PLT PLN ON REVERSE SIDE <br /> FOR-DEPARTMENT USE ONLY <br /> PHASE DATE S,,30-7? <br /> APPLrrATION ACCEPTED BY <br /> ADDITIONAL COMMENTS : ' <br /> PHASE II GRO!,'T INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE _�- 79 INSPECTION BY DATE 6� I l I <br /> r .f - 4 T f 5/79 <br />