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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F�6�FUICE 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 79-%94v- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR TELL CONSTRUCTION OR PUMP PERMIT Date Issued 4/, -;L7-172 <br /> This Permit Expires 1 Year From Date Issued ;arf <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 Healtkj <br /> District. <br /> EXACT STREET ADDRESS .zCITY/TOWN / c <br /> Owner's Name �`� _ p ,amu Phone <br /> Address !`a yz fly .��. - Ci ty?GG���. <br /> Contractor' s Name License#:?,6,5/ 2� Phone /3 <br /> IS CERTIFICATE OF WORK r1AN'S COMIPENSATIOfI 11111SURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIRJa PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Dornestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor /00 CW X!` <br /> Type of Pump ,-e- 6 H.P. <br /> PUMP REPLACEMENT: r] 5tate Work Done 7 AA,tco N-CU) S'a,6 4A) Q4rS11Ze <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth,' <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local - <br /> Health District. Home owner or licensed agent' s signature certifies the follow <br /> "I certify that in the performance of the work for which this permit is issu d I shall <br /> not employ any person in such manner as to become subject to Workman 's Iration <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPA T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B,/000 <br /> DATE �/ �.�= ► <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION! BY DATE INSPECTION BY TE <br />._EH_142f_ - Ray_ 12-77 - -- - __ 1178 2M s <br />