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SAN JOAQUIN LOCAL HEALTH DISTKIC] ° <br /> --F R 0 i°ICE ..USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. t 5 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued �• <br /> This Permit Ex i res'1 Year From Date Issued <br /> Complete In Triplicate.) �, Ep <br /> 6/gin <br /> ADpli,cation is Hereby made to the San Joaquin Local Health District for a' permit to construct <br /> Lad./or° install the work herein described. This application ismade in compliance with San <br /> oaquin County Ordinance No-'j, 1862 and the Rules and Regulations of the .San. Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS �A CITY/TOWNACA fn,ao <br /> Owner's Name Phone 31,04- 7,3 <br /> Address <br /> City . - <br /> t Contractor' s Name License# Phone <br /> i _ . <br /> S CCRTiFICATE 0 IdORVtPJ S CJS PEIJSATIOtJ I JSURI� aCE OPJILE�1rlITF4 SJLHp. YES NO <br /> TYPE OF WORK (Check) : NEW WELLJjZL, DEEPEN [I RECONDITION Q DESTRUCTION <br /> WELL` CHLORINATION ❑ WELL ABANDONMENT ED OTHER <br /> PUMP INSTALLATION ,R:L, PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO -NEAREST-:"- SEPTIC­TANK �SEWER -LI-NES]6i�q�P—T PRI-V <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBL DOMESTIC WELL .4 <br /> INTENDED USE TYPE' OF WELL CONSTRUCTION -SPECIFICATIONS <br /> Industrial . Cable Tool Dia. of Well Excavation -' <br /> Domestic/private Drilled Dia. of Well Casing° I ' <br /> Domestic/public Driven Gauge of Casing /QL <br /> Irrigation —Gra-vel Pack Depth of Grout Seal .. <br /> Cathodic Protections: Rotary Type of Grout , <br /> Disposal Other Other Information <br /> i Geophysical ,°, Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of,' Pump - 'H.P. <br /> PUMP REPLACEMENT: Q State Work -,Done ' <br /> . t <br /> PUMP REPAIR: ❑State Work Done -- <br /> DESTRUCTION OF WELL: WelljDiameter Al Approximate Depth <br /> ` Describe Materia ,`and Procedure <br /> a.14 <br /> 'and <br /> hereby cervify that -I have prepare'dthis application and that the work will be done in acco,rdar <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin,.' oca <br /> Health Dis'tr'ict. Home owner or licensed agent's signature certifies the following: <br /> "I cervify that_i-n-the`per-fo,rmance,,�of- the work far wh-i ch th.is_pe.r-mit_-.i-s-As sued.,_I._s.ha11_ <br /> not employ any person i!n such runner as to become subject to Workman' s Compensation <br /> laws of California. " <br /> I WILL CALL, FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: . DATE: 42 <br /> # iDR PLOT PL N ON REVERSE RESIDE) <br /> FOR DEP RTM T USE ONLY <br /> :t PHASE I <br /> i <br /> APPLICATION .ACCEPTED BY �� S 1'---ti_ _ �_.. --- . DATE 1-7-/_7. - <br /> ADDITIONAL COMMENTS: Gi <br /> PHASE II GROUTi INSPECTION PHASE III F AL LNSPECTION <br /> INSPECTION BY " DATE .7 INSPECTION BY DATE /4let), <br /> CU 1A9 r_ Db 1'9-77 <br />