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-- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton,,. CA 95205 Permit No. —6Z S <br /> Telephone: (209) 466-6781 , r <br /> APPL'J CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7f <br /> (Complete In -Triplicate)' i <br /> 3 .6. <br /> Application is hereby made to the San Joaquin Local :Health District for a .permit to construct - <br /> and/or install the work herein described. This application, is made in compliance with San f <br /> Joaquin County Ordinance No. 1862 and the Rules and' Regulations of :the San Joaquin Local Health <br /> District. L <br /> EXACT STREET ADDRESS <br /> CITY/TOWf�d� <br /> Owner's Name ?l/i1e 9,� Phone <br /> Address 0 <br /> City <br /> Contractor's Name— UY1� _ License �3 Phone r`' <br /> -IS CERTIFICATE OF WORKMAN'S COIMPENSATION INSURANCE ON FILE WITH SJLHD? YES I 0 <br /> TYN—PE ..OF WORK-(Check) NEW.WELL DEEPEN-❑ RECONDITION DESTRUCTION[] .' <br /> WELL CHLORINATION 0 r WELL ABANDONMENT ® ' OTHER(. <br /> PUMP INSTALLATION ERS PUMP REPAIR 0 PUMP REPLACEMENT [J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> - 1 <br /> . . .,SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGEPIT_ OTHER <br /> PROPERTY' i�INE-- PRIVATE DOMESTIC WELL PUBLIC D MESTIC WELL <br /> .-INTENDED USE` TYPE OF-WELL. CONSTRUCTION SPECIFICAT NS <br /> Industrial ' Cable Tool Dia, of Well Excavation r. <br /> Domestic/private 11Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Cas ' <br /> Irrigation i �" <br /> Gravel Pack Depth of Grout Sea <br />— Cathodic Protection ,/Rotary Type of Grout <br />.Disposal Y Other Other Information <br /> Geophysical _ Sur ace Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. � <br /> PUMP REPLACEMENT:- Stade Work. Done ' <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION-OF WELL: Well Diameter - -- <br /> Describe Materia an f rote ure Approximate Depth <br /> I hereby certify that I have preparedjthis application and that the work will be done in accordnc <br /> nrith San Joaquin County Ordinances , State LawS�,' and Rules and Regulations of the San JoaquinLocal. <br /> i alth Distri.ct-. 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 /> f WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />;IGNED <br /> TITLE: �1, _, DATE: - 42 <br /> DR W PL T PL ON REVERSE SIDET <br />'RASE I � FOR D -"PAR' MENT USE ONLY <br /> PPLICATION ACCEPTED BY i <br /> DDITIONAL COMMENTS : DATE <br /> PHASE II GROUT INSPECTIdL <br /> NSPECTION BYE DATE PHASE III FINAL INSPECTION <br /> 14 2b„Re v, 9/78 INSPECTION BY ¢' E <br />'-I <br /> 9/78 M <br />