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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P�FPCE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. - 5 7 <br /> Telephone: (209) .466-6781 a <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 1 <br /> A <br /> (Complete In' Tripl\icate)_. <br /> Application isheremade to the San Joaquin Local Health District-fora 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 Health ' <br /> Di strict. <br /> EXACT STREET ADDRESS ' psi : 401-W11,;? o v i� CKY/TOWN <br /> Owner's Name <br /> .s . Phone <br /> Address �t ZJ . �� i <br /> Contractor's Name <br /> Lice „� <br /> nse# `j;73-hone h—';6 7 <br /> IS C.ERTIFICATE�-OF WORKMAN'S CO";PEN TION INSURAINCE ON 'FILE WITH SJLHD? YES 0' <br /> TYPE`OF .WORK (Check) : NEW WELL L DEEPEN-(] '4 RECONDITION DESTRUCTION[nWELL CHLORINATION 0 WELL ABANDONMENT 0 . OTHER 0 - <br /> PUMP INSTALLATION 0 PUMP REPAIR P�F PUMP REPLACEMENT <br /> DISTANCE -TO NEAREST: SEPTIC TANK SEWER LINES _ -.. PIT PRIVY - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER - <br /> PROPERTY LINE - PRI°VATE DOMESTIC WELL_ -PUBLIC D MESTIC WELL <br /> INTENDED -USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well Excavation ` <br /> Domestic/private f Drilled Dia. of Well Casing <br /> Domestic/public A Driven Gauge of Casing <br /> Irrigation t: Gravel Pack Depth of Grout Sea <br /> Cathodic Protection s Rotary Type of Grout <br /> i Disposal Other Other Information k <br /> _Geophysical Surface Seal Insta ed b : ' <br /> PUMP INSTALLATION:. Contractor <br /> Type ofPumP ✓ H. .�. . .s'y ' t <br /> PUMP REPLACEMENT: 7]State Work Done .. ._ <br /> PUMP REPAIR: - <br /> [RState Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ <br /> Approximate Depth" - <br /> Describe Materia and 'Procedure <br /> } <br /> I hereby certify that I have prepared this .application and that the work will be done in accordanceI <br /> Kith San Joaquin County Ordinances , State Laws , and Rules;;and Regulations of the San ,Joaquin-Local <br />#ealth District, Home owner or, licensed agent's signature certifies the following: <br /> "I certify that .in the perfoance-of-the work: for which this permit is issued, I shall r . <br /> not employ -any perrmson in such manner as to become subject to Workman's Compensation - <br /> laws of California. 'C <br />[ WILL CALL. OR.A GROUT INSP 10 P 'IOR TO GR TING AND FINAL INSPECTION. <br /> SIGNED ITLE: DATE: <br /> PL ON REVERS SIDE <br />'HASE I I OR DEP RTMEN .USE ONLY <br /> TPLICATION ACCEPTED BYQLvr.Cr ti��a <br /> 46 <br /> I� t-c#r ovey- DATE /- 7/1V <br />►DDITIONAL COMMENTS: tU y ,c .' �yY <br /> PHASE II GROUT INSPECTION <br /> NSPECTION BY PHASE III FINAL INSP CT <br /> DATE INSPECTION BY DATE <br /> H 14. 26 Rev. 9/78 <br /> _yf�_ w.' ,:9178-. .,._2 <br />