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� 5v <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit NO. 29=L/2 .2 <br /> Telephone: (209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 5-/-5-72 <br /> (Comp 1ete In Tri pl i cai;e.)_ <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. <br /> EXACT STREET ADDRESS fie 'CITY/TOWN <br /> Owner's Name - Phone / <br /> Address S _. City <br /> Contractor's Name a Li cense Phone "�i' <br /> 7S­CERTIFiCATE°OF WORKMAN'5T0"9PENSATION 'I-KISIJRA" - OPf,FILE WITH SJLHD? YES No <br /> TYPE OF wORK (Check} : NEW WELL`i4 DEEPEN ❑ RECONDITION C] DESTRUCTION O <br /> WELL CHLORINATION [I WELL-ABANDONMENT 0 OTHER ED � f <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ - PUMP REPLACEMENT ❑ ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY --1 <br /> s. SEWAGE DIS OSA 7.IELDj�-p.r rCES�L/SEEPI GE PIT—_OTHER <br /> - PROPERTY LINFAfPRIVA-�ET D'.OMMESTIC WELL%:5 . PUBLIC DOMESTIC WELL— <br /> ki <br /> INTENDED USE t �TTYPE OF WELL ' CONSTRUCTION SPECIFICATIONS . <br /> Indus-trial Cable Tool Dia. of Well Excavation +� <br /> Domestic/private Drilled Dia. of Well Casing Lf <br /> Domestic/public l Driven j Gauge .-of Casing <br /> Irrigation ZGravel Pack r Depth of Grout Sea l ' <br /> Cathodic Protection _.X.Rotary w. Type of Grout -- <br />—Disposal Other_;Other z Other Informat7on <br /> Geophysical ° Surface Seal Installed b : <br /> PUMP- INSTALLATION: Contractor k <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State,Wo rk Done <br /> PUMP REPAIR: ❑StateWork Done <br /> DESTRUCTION OF WELL: Well Diameter .. 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 /> klealth 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 4 <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of Californi _ <br /> I WILL CAL ORA G TJ4PE9fX PRIOR TO GROUTING AND A'FINAL INSPECTION.. ' <br /> 5IGNED TITLE: ' DATE:. ` <br /> TQ PLOT PL ON REVER IDE <br /> FOR DEPARTMEN USE ONLY <br /> aHASE I <br /> PPS LIGATION ACCEPTED BY J DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE I - GROUT INSPECT ON PHASE III FINAL INSPECTION ' <br /> INSPECTION BY 4/ ATE INSPECTION B DATE <br />:H 14 26 Rev. 9/78 / ,�,.. - 9/78-_ .-:.. 2M <br />