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40-1' SAN JOAQUIN }OCAL HEALTH DISTRICT <br /> uFFICE USE: 1601 E. raxeltor Ave. , Stockton, CA 9:5205 'Perini t No.�� <br /> Tel epnone; 1209? X966-6781 i <br /> ._.. � 'i?cte i55idE'd lam- -rt�� <br /> APPLICATION FOR WELL CONSTRUC710N OR P 'MP PERMIT <br /> This Permit Ex fres 3 Year From Date Issuea <br /> -~—`�%Complete In 'Trio irate <br /> ��licat,ion is- hereby made to the Sar; Joaquin Local Health District for a permit 40 construct <br /> plication <br /> install the work herein described. This a4colication s made an corpliance with 5,an <br /> a :;�, rynty Ordinance ' i°62 and the Rules and Regulations of the Sar! Joaquin Local Health <br /> r, <br /> AC's STREET ADDRESS-� _ <br /> CITY/TOWN <br /> Phone <br /> +per's Nia me <br /> -� City <br /> !Cress r <br /> mtrdctor's Name <br /> License#d Phone <br /> S CERTIFICATE Or 0!',Kt*1AN'S CC*,PE'tSATIL=.2k I'i51:RA."SC£ atd PILE W rTf! SJL9.C? YES ,✓''' f�C �� �-s <br /> „ , W , o n �JESTFt�.;CTTO'i71 ts� <br /> IPE OF t ORK (Check): NEW WELL0 DEEPEN RECONDITION Q � - `�' � <br /> WELL CrI <br /> P HLORINAT ION 0 WELL ABANDONMENT 0 OTHER r . <br /> PUMP INSTALLATION Q PLNIP REPAIR 0 PutAP R£PLACEEM N L3 <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRI'dY S� <br /> ------ <br /> S£'�iAGE GiSP�TI£LD LESS- F(�rLIS£EPAGE RT OTHER <br /> P SLI DOMEST I C-_1+ELL„ <br /> PROPERTY LINE -. PRiV'A D MESTIC WELL -.-- I1 <br /> INTENDED USE TYPE OF WELL - <br /> CONSTRUCTION) SPECIFICATIONS <br /> IntlstrG� - Gable ! Dia. of 'fie £xcavat'c+n <br /> oomestic/Private Drilled ilia. of Well lasing <br /> Doestic/public Driver. - Uauge of Casu <br /> m -- <br /> —Irrigation Gravel Pack Depth of Grout eaI <br /> Lathodic Protection Rotary Type of Grout <br /> Disposal Other tither Infoyi-Aation <br /> Geophysical Surface Seal insta ed b : =EEEJY <br /> UMP INSTALLATION. contractor <br /> Type of Pump .__.- <br /> `vMP R£'PLACE EV: C3 St to Work Done'_______:_r, <br /> t+. <br /> 11 <br /> ';UMP REPAIR: tate Work Done Y4 <br /> J£STRUCTION OF WELL: Well Diameter roximate Depth <br /> Describe Mderia and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br /> ,ith Sar, Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local <br /> iealth District. Home owner or licensed agent's signature certifies the following: <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 <br /> laws of California." <br /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROU'ING AND A FINAL INSPECTION. <br /> DATE <br /> yIGNE7 e, t9b4 _ <br /> TITLE:___ . <br /> . r _ � PLC, L t3ti REVERS F; <br /> -OR :EPR MEN; 'USE ,,LY <br /> BATE -7 <br /> s! . -i%ATICJN ACCEPTED BY <br /> 'ADDITIONAL COMMENTS- _ <br /> PHASE .1L GROUT INSPECTION PRASE III FINAL I,'�5PECTION <br /> NSPECTION BY DATE _ INSPECTION BY __._. DATE l --- <br /> ~ 1 17S 2M <br /> '4 1426 R v 12-77..77 ____ ........_.__.�.___.._.. .. <br />