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SAN JOAQUIN ,LOCAL HEALTH DISTRICT ' <br /> FFICE USE: 1601 E. Hazelton Ave. , <br /> Stockton, CA 95205 Permit No. .79-.� <br />{ Telephone'-e (205) 466-6781 pate Issued -7 <br /> APPLICATION FOR EL <br /> WL CONSTRUCTION OR PUMP PER <br /> This Permit Ex ires ,1 Year From',Date Issued <br /> Complete In Triplicate <br /> Application is hereby made toi the San Joaquin .Local Heal th. Di stri ct for a permit to- construct: ' <br /> aiid/or --install the work herein described. . This .application is made in compliance <br /> Countith y <br /> Joaquin County Ordinance No. f-.1862 and the. .Rules and Regulations of the. San Joaquin <br /> District. r <br /> EXACT' STREET ADDRESS O:10 CITY/TOWN '- - <br /> . Phone <br /> Owner' s Name �� • <br /> Address.. o�(a City <br /> Contractor' s Name , * 6 �. License#3p/8ps"Phone -��a I <br /> -w _A, <br /> '� CERTTFICATE OF JORKMAN'S COQ,14'-EN ATI0-1-1"ZSURANCE Ops FILE. WITH SJLHD? YES �,0 <br /> 1 1 �' Y <br /> R <br /> TYPE OF 'WORK (Check) : NEW WEL DEEP�N ❑ RECONDITION <br /> DESTRUCTION❑ . 1 <br /> - ,WELL CHLO�iR NATION D WELL ABANDONMENT Q OTHER 0 <br /> n. ; <br /> �i PUMP 'INSTALLATION j;� PUMP REQ I.R C! PUMP REPLACEMENT C� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PIT PRIVY C <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 Toa] Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout..,,Se�al <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal - Other Qth"er-Inforniati on <br /> t Geophysical Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type lof Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordan <br /> ' with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <br /> Health 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 /> G laws of California.` a <br /> I WILL CA A GROU SPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIG TITLE: DATE: -,1-3 -77 <br /> i <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> 4 FOR DEPARTMENT USE ONLY <br /> PHASE I � DATE <br /> APPLICATION ACCEPTED BY — <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT. INSPECTION PHASE III IAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY/. DATE <br /> CO 78 2M <br /> rt i 'I n nE n— 1 7 77 � ..., <br /> - <br />