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. � S w J ; ., ,- �-'-,-a"l.'--�.r.r.:,.e:_ -'.=ay., `.� vat-•-:....rE <br /> SAN JOAQUIN <br /> CAL HEALTH <br /> CT <br /> FFICE USE: �yY� 1601 E. Hazzelton Ave" Stockton, CAIC95 <br /> 205 Permit <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued // <br /> This Permit <br /> Expires -I Year From Date Issued <br /> Complete 'ln Triplicate <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 <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San. Joaquin, Local Health <br /> District. 7 <br />` EXACT-STREET ADDRESS 4�2 74 <br /> T <br /> t <br /> CITY I OWN <br /> Owner's Name Phone <br /> Address City <br />' Contractor's Name License Phone2 4G/ <br /> IS CERTIFICAT gF WORK IAN" C0MPENSA 7 Ik it �S CE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN ❑ RECONDITION DESTRUCTION C3 <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST.: SEPTTCITANK SEWER LINES PIT PRIVY_ <br /> SEWAGE <br /> DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 5 <br /> PROPERTY LINE -. PRIVATE DOMESTIC -JELL PUBLIC DOMESTIC WELL ' <br /> INTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS. - <br /> RI <br /> Industrial `�"'-""" , <br /> Cable Tool Dia. of Wel.-1 Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal i Other <br /> . Other Information � <br /> Geophysical Surface Seal Ins ailed b <br /> PUMP INSTALLATION: Contra ctor6;,_Ie 7 , 1 <br /> Type of Pumpc�;L H.P. I <br /> PUMP REPLACEMENT: State Work Don <br />-PUMP REPAIR: ❑State Work Done } <br /> DESTRUCTION OF WELL: Well Diameter <br /> ;-Approximate Depth <br /> Describe Material- and Procedure <br /> I hereby certify that I have prepared 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 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 subje <br /> laws of California." ct to Workman 's Compensation <br /> I WILL CALL FOR A G INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> I DR W PLT L N ON REVERSE SIDE <br /> FOR, DEPARTMENT USE ONLY <br /> PP <br /> LICATION ACCEPTED 8Y <br />%DDITIONAL COMMENTS : k <br /> DATE <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTTON BY_,,6� DATE / -?.6.-7 <br /> eq <br /> A 142b Rev-, 19-77 c�11 <br />