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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR -QFFICE USE: 1601 E. Hazelton. Av-e­,'S.tockton, CA 95205 Permit:No. - d 3-3 <br /> Telephone: (2.09) 466-6781 �APPLICATION- FOR WELT. CONSTRUCTION OR PUMP PERMIT <br /> Date Ied � <br /> This Permit .Ex i.res 1 -Year• From Date Issued ' <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local 'Health District for a permit to construct 3 <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 /> District. <br /> EXACT STREET ADDRESS �6 CITY/TOWN , �v <br /> Owner's Name Phone 42 <br /> Address Ci ty_SEaG,(��o�� <br /> Contractor' s Name O- License# Phone 5 <br /> IS `CERTI-FICATE-OF WOPKtiAll-S COMPENSATION TP,01R NCE ON FILE -WITH .6JLHD? YES --No _ <br /> TYPE OF WORK .(Check) : NEW WELLOO DEEPEN C7,= -RECONDITION ® DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 � <br /> 4 PUMP INSTALLATION Q PUMP REPAIR 0 PUMP REPLACEMENT [] � <br /> DISTANCE TO NEAREST: SEPTIC .TANK ,5Q' SEWER. LINES SDS PIT PRIVY �- <br /> SEWAGE DISPOSAL( FIEL ",t CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINFA9. RIVATE' D-0 ESTIC WELL-- ' PUBLIC DOMESTIC WELL -,= <br /> INTENDED,USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �► <br /> Industrial Cable Tool Dia. of Well Excavation 116 ' + <br /> Domestic/private -Drilled Dia. of Well Casing ' ; <br /> _Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack' Depth of Grout Sea ----- <br /> Cathodic Protection Rotary Type of Grout �-- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal 'Inst�a 1� ---- <br /> PUMP INSTALLATION: -�-T-Contractor.--- Y� <br /> k <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 7]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 accordance <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> lealth 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 /> IWILL C L FOR GROU IN EC 4 PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> aIGNED TITLE: DATE: <br /> DR W PLOT L N ON REV 5I E <br /> FOR DEPARTMENT USE ONLY <br /> CHASE I <br /> DATE �� �£ <br /> aPPLICATiON ACCEPTED BY <br />%DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE- III FINAL INSPECTION <br />;NSPECTI.ON. BY DATE //INS ECTION BY -� DA„TE f� f <br /> k,A4, Rau_- 12-77- _ tf �'G -+J 1a tc.. - `�n �. <br /> 4 /7 8 2M <br />