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.01 <br /> t FFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone:p , _ (209) 4666781 <br /> 4 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> Application is hereby made <br /> (Complete In Tri'pl`icate) <br /> kto the San Joaquin Local Health District fora permit to <br /> and/or install the work herein described. , This application is made in compliance with: San <br /> Joaquin County Ordinance Not 1862 and the Rules and RegLilations of the S construct <br /> District. - an Joaquin Local Health <br /> h <br /> EXACT STREET ADDRESS 7� ` � /300 /.r1 <br /> z3C�d �1� <br /> Owner's Name ITY/TOWNc1j, C' <br /> f a <br /> Address r � one 9.5 <br /> r a $C1 on/ �78 2-� �r n 7,, <br /> Contractor's Name City <br /> er Licensed Phone <br />' IS CERTIFICATE OF WORKMAN'S �CO.iPENSATIOPJ IPJSURA'ZCE 0N FILE WIT SJLHD.? <br /> H YESNO <br /> 7 <br /> TYPE OF 'WORK (Check) : NEW WELL DEEPEN p RECONDITION [� DESTRUCT II! <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OVER [,] N� <br /> PUMP 'INSTALLATION ❑ PUMP REPAIR Q PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRY <br /> S <br /> SEWAGE DISPOS- FIELD CESSP OL/SEEPAGEPIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC—DOMESTIC <br /> INTENDED OSWELL <br /> E . -- <br /> — .Industrial TYPE OF -WELL., CONSTRUCTION SPECIFICATIONS <br /> Cable Tool ` <br /> Domestic/private Dia. of Wel Excavatign I <br /> _____Domestic/public .Drilled Dia. of Well Casing <br /> --- Irrigationj Driven Gauge of Casing <br /> z / Gravel Pack Depth of Grout <br /> _� Cathodic Protection/ Rotary t Sea ► <br /> _Disposal Type of Grout <br /> _..Geophysical Other_ Other Information <br /> Surface Seal Instia ed <br /> PUMP INSTALLATION: ,'Contractor <br /> k <br /> / Type of Pump <br /> PUMP REPLACEMENT:H •P. ' <br /> []State Work Done <br /> PUMP REPAIR: ' ❑State Work Done <br /> DESTRUCTION OF WELL l Well.- Diameter <br /> `= Describe Materia and Proce ure p rox'mate eff 0 <br /> I hereby certify that I have prepared this application <br /> with San Jo.aqulin CountyY. Ordinan.ces. Sta.te. .Laws and Ru7esdand Regulatthat the �answoflthe Sanbe e in accordant <br />`lea"I Disti^Mict. '^Ffome bwner 'or licensed agent's `signature certifies the following: Joaquin Local; <br /> "I certify that in the performance of the work for which this permit is issued, I <br /> not employ any person in such manner as to become subject to Workman 's Compensational <br /> laws of California. " ° l. <br /> ILLCALL FOR A GROUT I,N PECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNE e ' <br /> TITLE-:_ <br /> DR OT L ON R£VER � <br /> HASE j: f OR DEPARTMENT USF.ONLY <br /> PPLICATION ACCEPTED BY w�- _ - / <br /> DDITIONAL-COMMENTS: a - F DATE 2-15 7 <br /> I PHASE II GROUT INSPECTION <br /> ISPECTION BY DATE PHASE III FINAL INSPECTION -� <br /> 1 14 26 Rev. 9/78 INSPECTION BY DATE ,:F <br />