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�......- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Stockton, CA- 95205 Permit 2 2 <br /> NO. <br /> OFFICE USE:- - 1601 E. Hazelton Ave. , . <br /> FOR Telephone: (209) 466-6781 pate Issued - -7 <br /> APPLICATION FOR <br /> WELL CONSTRUCTION OR PUMP PERMIT <br /> (Complete In Triplicate) <br /> the San Joaquin Local Health District for a permit to construct <br /> Application is hereby made to applicationis made incompliance with San <br /> and/or install the work herein described. This app <br /> Joaquin County O <br /> rdinance. No. 1862andthe Rules and Regulations of the San Joaquin Local Health <br /> bistrict. CITY/TOWN � <br /> EXACT STREET ADDRESS / � Phone -7 � . <br /> Owner's Name City <br /> Address 9-14' / Pha <br /> License sne .3 <br /> . _ . <br /> Contractor's Name <br />` T WORKMAN'S C0IMPENSATION INSURANCE ON FILE WITH SJLHD? YES O <br /> IS CERTIFICATE -OF <br /> TYPE OF WORK (Check) : NEW WEtL C1 DEEPEN Ci EABANDONMENT Q DEOTHERCJ IONE2 <br /> WELL CHLORINATION Q WELLiR <br /> q� <br /> PUMP INSTALLATION E3 PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK S SEWER LINES .. . .. L/SEEPAGEPIT YPIT OTHER 07 <br /> I - <br /> SEWAGE DISPOSAL FIELD CESSP�b / r <br /> PROPERTY LINE- PRIVATE DOMESTIC WELL------� PUBLI DOMESTIC WELL <br /> } CONSTRUCTI N SPECIFICATIONS.., <br /> INTENDED USE TYPE OF WELL <br /> Cable Tool Dia: of We 1 Exc1 g ion <br /> Industrial Drilled Dia: -of Well Casing <br /> Domestic/private j Gau e of Casing <br /> y Domestic/public s..Driven 9 <br /> ,Gravel Pack Depth of Grout Sea , <br /> Irrigation Rotary Type of Grout <br /> ( Cathodic Protection Other Information <br /> Disposal "' i Other <br /> t *; Surface Seal Insta ed b <br /> ( PUMP, INSTALLATION: Contractor • I.as <br /> r Type of Pump <br /> tate Woirk_-Done <br /> PUMP REPLACEMENT: _� ; <br /> ` PUMP REPAIR: , ❑State Work Done Apprax'mate Depth- <br /> DESTRUC_T_I�ON'V WELL: Well Diameter p <br /> .. Describe Materia an Procedure 4- <br /> kVhereby certify that I have prepared this appliandiRuleans dandaRegulations oflthe San-JoaquinoLocal <br /> with, San Joaquin County Ordinances , State Laws, <br /> lHeal�th District. Home owner or: licensed agent' s signature certifies the olssued,: ' <br /> i I certify that in the performance of the work for which this permit i issued, I shall <br /> 7 not employ any person in such manner as to become subject to Workman' Compensation— <br /> not <br /> laws of California." <br /> I WILL CAL 0 A GROUT I ECTION PRIG TO GROUTING AND A FINAL IN <br /> SPECTi N. <br /> TITLE: . DATE: 6 �21r�� <br /> .SIGNED D ON REVERSE IDE <br /> _ L. <br /> R DEP RTM NT USE NL , <br /> � <br /> , PHASE I # DATE J-2 ' <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION ' TE 1-�v 17 7 <br /> INSPECTION BY DATE INSPECTION BY <br /> �2 /78 ' 2M <br /> rte 1 n 7C no,. 0/79 <br />