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raL� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> � CA 95205 Permit No. 2,3--6 ,r . <br /> Car�c - <br />�_..EQR OF FI E USE: � 1601 E. Hazelton Ave. , Stockton, <br /> Telephone; (209) Date Issued'?-a•-7q <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (Complete In-- Triplicate) f 7c? — 2,20— � <br /> tion is hereby made to the San Joaquin Local Health District for a permit' ta construct <br /> Aoplica application is made in compliance with San <br /> and/or install the arork herein described. This <br /> County Ordinance Na. 1862 and the ,Rules and Regulations of the San Joaquin Local Health <br /> Joaquin Cou Y �.�- . <br /> District. 4- �osr 2;a c. sa,�.�h t., , <br /> m .. 5�+. ... � �� .�a�s(CITY/TOWN <br /> EXACT STREET ADDRESS / Phone <br /> WL <br /> Owner' s Name r <br /> 11�. <br /> �"�1 City 74 <br /> Address �� <br /> Li cense# y�'Phone <br /> Contractor' s Name - N0. <br /> ERTIFICATE OF I�ORKr�fir�'S <br /> ��,P rdSATIO"1 'ItISORArNCE ON FILEWITII SJLHD? YE5IS C `J <br /> F WORK Check) : NEW WELL Ci " DEEPEN RECONDITION Q QESTRUCTION d <br /> TYPE O ( WELL CHLORINATION (� WELL ABANDONMENT E7. OTHER 0 <br /> PUMP INSTALLATION [D PUMP REPAIR <br /> PUMP REPLACEMENT <br /> PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT <br /> PIT OTHER_A—L — <br /> PROPERTY <br /> SEWAGE DISPOSALFIELD LINE - PRIVATE DOMESTIC WELL --- PUBLIC DOMESTICtiINTENDED USE TYPE OF WELLCONSTRUCTION SPECIFIC <br /> Industrial <br /> Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public Depth of Grout Seal <br /> Irrigation Gravel Pack Type of Grout <br /> — , -- Rotary <br /> fk Cathodic Protection Other Other Information <br /> Disposal Surface Seal Installed b <br /> Geophysical <br /> PUMP INSTALLATION: Contractor H.P. <br /> P Type of Pump <br /> PUMP REPLACEMENT: State Work Done , <br /> State Wark Done <br /> PUMP, REPAIR: Approximate Depth <br /> DESTRUCTION .OF WELL: Well Diameter <br /> Describe Materia? and Procedure _ <br /> licati.on and that the work will be done in accorda <br /> I hereby certify that I have prepared thisLapp <br /> w <br /> ith San Joaquin. County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loc <br /> Health District. Nome owner or licensed agent' s sforawhichcthisre fpermities eisoissued, I shall <br /> "I certify that in the performance o <br /> F` not employ any person in,such manner as to become subject to Workman's Compensation <br /> laws of California . " - <br /> I- WILCA!L FOR A GROUT INSPE 0 PRI . TO GROUTING AND A FINAL INSPECTION. <br /> L DATE: <br /> TITLE: <br /> SIGNE - "'� DRAW PL T PL ON REVERSE SIDE <br /> FOR DEP RTMEN SE ONLY <br /> PHASE I f DATE <br /> J�PPLTCATION ACCEPTED BY <br /> P,DDITIQNAL COMMENTS: PHASE III INAL NSPECTION <br /> PHASE II GRO��T INSPECTION INSPECTION B DATE <br /> INSPECTION BY DATE <br /> �- � L� 5/7 <br /> �.i4 is 26 Rev. 9/73 <br />