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r/ <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT i <br /> f FICE USE:.. I601 E. Hazelton Ave. Stockton CA 95205 Permit No. 7,f <br /> � Telephone: (209) 4667,6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/a/�7,L <br /> (Eomplete.^In Triplicate), ' <br /> Application is hereby made to the San Joaquin Local Health Di'str.ict for a permit to construct <br /> and/or install the workiherein 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. ` <br /> EXACT STREET ADDRESS CITY/TOWN <br /> j Owner's Nam Phone <br /> Address e- i _ - ... :. C_itji `" <br /> contractor's Name �� �' i cense#,,3, Phone F /k- <br /> ,�� � h <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES^ go <br /> TYPE- OFA.,WORK-_(Check)_:--.,;;I�EW.-WELL-II rDEEPEN 0 -= .RECONDITION( ; DES_T,RU.CTI-ON.[.� <br /> WELL CHLORINATION D , WELL ABANDONMENT 0 OTHER 0 <br /> !,PUMP INSTALLATION Q ' .PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: :SEPTIC TANK SEWER LINES . .... .. PIT PRIVY <br /> SEWAGE DISPOSALTELD CESSP OL/SEEPAGE PIT OTHER G ( <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 /> I LDomestic/privateDrilled Dia. of Well Casing <br /> Domestic/public ' riven Gauge of Casing ` <br /> - Irrigation ZGravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout Cal me A�,+ <br /> Disposal ' Other Other Information <br /> Geophysical Surface Seal Installed b m:C,r ' <br /> ' PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> E PUMP REPLACEMENT: ']State Work Done" =w 'F <br /> ? PUMP REPAIR: <br /> i�i❑State Work Done <br /> - - <br /> ' DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> --Descr i-be-Materi-al---ana Procedure <br /> — -- <br /> I hereby certify that Ii have prepared th.iswap-0,1cation and that the work will be done in accordant <br /> with San Joaquin County Ordinances, State `Laws; and Rules and Regulations of the San Joaquin Local <br /> Health"District., Home wner or licensed'. gent' s signature certifies the following: <br /> "I certify that�in the performance he,.work for which this permit is issued, I shall <br /> not employ "any persn in'suc_h manner as 'to become subject to Workman's Compensation... <br /> laws of California-.,."I , r �. ...� _ I ." <br /> �I WILL CALL FOR A GROUT,IiLNSPECTION PRIOR TO GROUTING AND A FINRL INSPECTION, r <br /> �J <br /> SIGNED:. <br /> TITLE: du/Ke DA <br /> (DRAWP L N ON. REVERSE SIDE). <br /> PHASE I <br /> �:;, u`; FOR DEPARTMENT USE70NL�Y <br /> � ,� <br /> APPLICATION ACCEPTED BY.i'``s z:� a,��/' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE TI GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION -BYzr_: -gip DATE �/a -� ��� � i� INSPEC,TION.,BYt ATE �-1 <br /> EH 14 26 Rev. 9/78ti = �._ �, d . . 9/78 . . 2X <br />