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`0' SAN JOAQUIN LOCAL HEAL-IH DIS-FRIG-1 � <br /> FOR.-OFFICE USE: 1601 E. Hazelton-Aveii ,Stockton, <br /> CA 95205 Permit No. <br /> r Telephone: (209) 465-,6781 Date Issued J- 3-� <br /> j <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex fres` 1 Year From Date Issued <br /> P;, <br /> Complete In Trip icate <br /> Application is hereby made to the San Joaquin Localiealth Districtmade iorca permit twitho construct <br /> and/or install the work her..ein1described. This appl <br /> Joaquin County Ordinance No. d. Regulations of ,the San Joaquin Local Health <br /> 1852 and the Rules an <br /> q / <br /> District. 'CITY/TOWN-&t rit/ _ <br /> EXACT STREET 'ADDRESS` ]2 i S 4 C! 77/ cN Q Phone <br /> . ,� <br /> Owner's Name b-eI r <br /> Address 2 0 r 7A . 0 ,a0 4,62 9S23JCity <br /> Contractor's Name C L4fZ k, W CJ 'F Cl�4 <br /> Li cense# 6 0 2_. Phones 2� <br /> IS CERTIFICATE of W04'WANIS CO!,IPENSATIO"a II3SURA"lCE ON FILE WITHSJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Ltil DEEPEN ❑ EL�ECONDITIONO ABAND4NMENT p DESTRUCT ION <br /> ED <br /> WELL CHLORINATION [3 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK 13 'SEWER LINES W �[=PIT PRIVY I N�— <br /> SEWAGE DISPOSALFIELD /5-a -i-CESSPOOL/SEEPAGE PIT E4 ICRW£��Q It 3 <br /> 'PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC <br /> DED USE TYP OF W <br /> ELL CONSTRUCTION SPECIFICATIONS <br /> i INTEN Dia, of Well Excavation <br /> Industrial Cablel <br /> ��Domestic/private Y Drilled Dia, of Well Casing <br /> Driven - Gauge of Casing <br /> Domestic/public Gravel Pack Depth of Grout Sea' .SCS ' <br /> Irrigation Type of Grout CE <br /> k Cathodic Protection Rotary, <br /> Disposal Other ` Other Informatloh <br /> Surface Seal Inst led b : <br /> Geophysical �,.._.�<-_--��� . . - � i <br /> PUMP INSTALLATION: Contractor H.P. <br /> Typejbf Pump' <br /> PUMP REPLACEMENT: ]state -Work Done �!# <br /> State Work Done <br /> PUMP REPAIR: rp ll , �. Approximate Depth <br /> DESTRUCTION OF WELL: Descr�be -Materijh-an Procediameterure <br /> I hereby certify that*I have prepared this application and that the work will-be done in accordane <br /> the San Joaquin Local <br /> with-San Joaquin County Ordinances , State Laws , and Rules and Regulati-on5 of <br /> Health District. Home. owner or \l^icensef then works forawhichture cthisfpermitthe <br /> isoissued, I shall <br /> "I certify that in the performance o <br /> not employ any person in such manner as to become subject to Workman' s Compensation <br /> laws aft lifornia." <br /> I WILL CA OR G NS ECTION PRIOR TO GROUTING AND A FINAL INSPECTION. DATE: I <br /> SIGNED 41 TITLE: <br /> DR W PL L N ON REVERSE SIDE - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f DATE a <br /> APPLICATION ACCEPTED BY - <br /> ADDITIONAL COMMENTS: 6- 3 PHASE III FINAL INSPECTION <br /> PHASE II GROU INS CTION DATE <br /> INSPECTION BYW,Y�9 <br /> DATE -Q9- INSPECTION BY <br /> 'F 1./78 <br /> ,n 7'1 <br />