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T-T SAN JiIAQUIN LOCAL HEALTH U15-1 KIL <br /> .;, <br /> OFFICE USE: 1601 E. Hazelton _Ave. Stockton, CA 95205 Permit No. 3 <br />-�OR 0 � <br /> Telephone':r( 09) .466-6781 <br /> Date Issued/ <br /> APPLICATION FOR .WELL CONSTRUCTION OR PUMP PERMIT <br /> -S 7� <br /> This Permit Ex ires I Year .From Date Issued <br /> Complete In Triplicate y <br /> Application is -hereby made to: the San. Joaquin Local Health District .fora permit to construct <br /> and/or install the work herein described. 1his' application is made in compliance with San <br /> '2oaquin County Ordinance No. 1862 and the Rules and. Regulation.s of the San Joaquin Local Health <br /> Cistrict. <br /> CITY/TOWN- <br /> EXACT STREET ADDRESS . 10 IV, JE Ai4i'm <br /> 77—Owners Name <br /> � Phone ry � <br /> Address City .hoc <br /> Contractor' s Name �� License / - Phone <br /> ell 2- P110 <br /> IS CERTIFICATE OF IJOP.Kt1AN'S C0f1PENSATIOfJ I" URA*JCE Ofd FILE WITH SJLHD? ""'YES- NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN 5! RECONDITION Q DESTRUCTION <br /> WELL CHLORINATION L WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> ,SEWAGE.• DISPOSAL FIELD�t CESSPOOL/SEEPAGE PIT �— OTHER - <br /> PROPERTY LINF04 PRIVATE DOMESTIC WELL��- PUBLIC 'DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> Industrial ��Cable Tool Dia. of Wel l,- Excava- ion1 <br /> Domestic/private Drilled Dia. of Well Casin " <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 ' 0. <br /> Geophysical C Surface Seal Installed b —� <br /> PUMP INSTALLATION: Contractor I' <br /> Type of Pump .r H.P. <br /> PUMP REPLACEMENT: F]State Work Done J6 <br /> I PUMP REPAIR: Q State Work Done <br />"' DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure <br /> I t S <br /> I hereby certify that I havelprepared 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 /> Health District. ' Home owner)or licensed agent' s signature certifies the following: <br /> "I certify thatsin. 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 /> I WILL CALL FORA CxROUZ Ia6PXCTION PRIOR TO GROUTING AND A FINAL INSPECTION. ; <br /> SIGNED TITLE: g DATE: <br /> (DRAW PLT L N ON REVER SIDE <br /> FOR DEPA TMENT U E ONLY <br /> , PHASE I ATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: IiEzz, LIZ-- <br /> PHASE II GROUT INSPECTION PHA II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 5—/7�z <br /> L/.78 <br /> CLI 1A9a Da., 19_77 . ._. .- <br />