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` SAN JOAQUIN LOCAL HEALIH UISIRICT <br /> FFI`C,.E_ USE: 1601 E. Hazelton Ave. , <br /> Stockton, CA 95205 Permit No: <br /> Telephone: (209) 466 6 <br /> Datet'Issu.,d <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ices 1 Year From Date Issued <br /> Complete In Trip icate <br /> Application is hereby made toithe San Joaquin Local Health District for a permit to construct <br /> pliance with San <br /> and/or install the work. herein.described This application is made in com <br /> Joaquin County Ordinance No. 1862 and .-the Rules and Regulations .of the San Joaquin Local Health a <br /> District. <br /> EXACT TREET ADDRESS U CITY/TOWN <br />. Owner'.s Name L �..� Phone <br /> Address �I S �L City 5 C ,k <br /> ` Li cense# PhoneL162- <br /> -;7 <br /> e Z"`.S�J <br /> Contractor' s Name GI. WE�� @ I • r <br /> IS CERTIFICATE OF WORKMAN'S CO}iPENSATI0P1 I�SSURAINCE ON FILE WITH SJLHD? YES N0� <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN EEEro RECONDITION ® DESTRUCTION F1 <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION El PUMP REPAIR❑ PUMP REPLACEMENT 1 LA: <br /> ' "'SPIT PRIVY <br /> DISTANCE-JO NEAREST-; SEPTIC: TANK 20L F SEWER LINES ZOD — <br /> �.�, SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER q,�¢ <br /> PROPERTY...L-IN-£. -..PRIVATE=DOMESTIC--WE-LL- = 'PUBtiIC"DOMESTIC WELL <br /> �`' ' ' ` CO <br /> � ' NSTRUCTION -SPEC-IF-I CATIONS _ <br /> INTENDED USE ' -�t TYP '�! E!'L.-. •� x �� <br />'E Industrialso Cable Tool Dia. of Well Excavation <br /> Dome c/priv..ate ( Drilled Dia. of Well Casing 0 <br /> estic/publ`ic 'Driven Gauge of Casing <br /> Irrigation <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary' Type of Grout - --- y <br />` Disposal Other Other Informations <br /> Geophysical <br /> Sur/face Seal Insta ed b r '' <br /> PUMP INSTALLATION: Contractor d <br /> Type 'of Pump <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: CD State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> t Approximate Depth <br /> Describe Material ana Proce urs <br /> I hereby certify that I have prepared this application and that the work willibe doneJin uinoLocal <br /> ' <br /> with. San Joaquin County Ordinances , State Laws , and Rules and Regulations of the q <br /> Health District. Hone owner or licensed agent' s signature certifies the following: <br /> "I certify that in the performance of the work forlwhich this permit 'is issued, I shall <br /> not em oy any person in such manner as to becom6!subject to Workman's Compensation <br /> laws Calif or ia." <br /> I WILL C L OR A U CTI PRIOR TO GROUTING!AND A FINAL INSPECTION. <br /> TITLES _ <br /> DATE: 6 7P <br /> ,R <br /> SI.GNEDs _ _ _ <br /> QR�W.PL T PL N ON REVERSE SIDE <br /> FOR DEPARTMEN USE ONLY ! <br /> PHASE I I <br /> 4 APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: .III PHASE FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE�6 <br /> INSPECTION BY 0 DATE INSPECTION BY <br /> - 11/78 214 <br />