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_ rSAN JOAQUINILOCAL HEALTH DISTRICT <br /> ,10R . FFICEMUSE: 1601 E. Hazelton ,Ave. ,; Stockton, CA 95205 Permit No, 9•. <br /> Telephone: (209). 466-6781 <br /> . . ...._. .... (ADate Issued � �..?.PPLICATION FOR WELd CONSTRUCTION OR PUMP PERMIT <br /> (tomplete In Triplicate)- <br /> made to the San Joaquin Local Health District for a permit'to construct <br /> Application �s hereby <br /> and/or install the .workherein described. This application is made' in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Roles and Regulations of the San Joaquin Local Health <br /> District. <br /> zCITY%Tow N S_ 21. o <br /> EXACT STREET ADDRESS AlS <br /> Owner's Name l� N Phone q O X24 <br /> :Address �IN "City ` <br /> Contractor's Name �� License# Phone -21 / <br /> E <br /> IS CERTIFICATE OF WORKMAN'S .CQMIPENSATIOH iP15URA"f ON FILE WITH SJLHD? YES V N—O. <br /> TYPE OF 'WORK (Check) : NEW WELL Ll DEEPENb RECONDITION DESTRUCTION[I _ <br /> WELL CHLORINATION 01' WELL ABANDONMENTED OTHER El <br /> PUMP INSTALLATION 01, PUMP REPAIR 0 PUMP REPLACEMENT [3 v <br /> bISTANCE TO NEAREST: SEPTIC TANK-50 + SE"WER LINES,_<D_,�,....,,PIT PRIVY <br /> SEWAGE QISPOS l� FIELItg� CESSPOOL/SEEPAGE PIT - OTHER <br /> F PROPERTY LIN�=4PRIV,ATE DOMESTIC WELL-TO-L- PUBLIC DOMESTIC WELL <br /> INTENDED USE i. TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> - Industrial Cable Tdol Dia. of Well Excavation <br /> t�Domesti c/private;, -Dri l led Dia. of Well Casing <br /> Domestic/public Driven y Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Sea �p 1 <br /> { Cathodic Protection ___Rotary Type of Grout - <br /> Disposal Other Other Information <br /> Geophysical � � __ Surface Seal Insta ed by: <br /> PUMP INSTALLATION: Contractor <br /> 4 Type of Pump ill H H. . <br /> .,, PUMP REPLACEMENT: []State Work Done :�ff <br /> PUMP REPAIR: QState Work Done <br /> ` DESTRUCTION OF WELL: ,Well Diameter !. Approximate Depth <br /> Describe Materia an Procedure <br /> 4I hereby certify that I�ihave prepared this11'application and that the work will be done in accordant <br /> !With 'San Joaquin County, Ordinances , State,.Laws , and-;Rul esu and- Regu-1 ati ons of the San Joaquin Local <br /> Health District. Homeowner 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 Cal iforniall I� <br /> I.WILL GALL FOR A GRO T PE PRIOR T:p GROUTING AND A`FINAL INSPECTION. <br /> ;SIGNED iM �� TITLE: 4, A, DATE: <br /> if (DRAW PLU11 PLAN ON REVERSH SID <br /> OR QEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE-2ZQ <br /> ADDITIONAL COMMENTS: <br /> iM <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY ac-- I� - DATE, s/o-7 � INSPECTION BY DATE <br /> EH 14 26 Rev. 9/78 9 78 <br />