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E FFICE USE: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave, , Stockton, CA 95205 7latelssued,5 <br /> No. <br /> =4 _ Telephone:. (209) 46.6--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (1;oinp 1 ete I n Tri p 1 i ca to <br /> )i <br /> I Appiicati . <br /> an is hereby made to the San Joaquin. Local Health =District fora a xa <br /> and/or install the work herein described. This application is .madei,in <br /> Joaquin' C©bnty Ordinance No. 1862 and the Rules and tcati tions -of p mit -w construct <br /> compliance- with i�ance� wi th San <br /> District,` the San Joaquin Local Health <br /> EXACT• STREET ADDRESS <br /> G /4l�C xx <br /> Owner's Name' _ CITY/TOWN <br /> Address 2-e e - <br /> Phoneme <br /> Contractor's Name <br /> C i ty <br /> I5 CERTIFICATE OF WORKMAN'S COfTPEP1SAT License# Phoneg F�� S��C� <br /> IOPd INSURA"�10E-ON FILE WITH 'SJLHD? . YES 4 g�� . � <br /> TYPE OF WORK (Check) : NEW WELLj~ , DEEPEN 0 RECONDITION' � � O ` <br /> tr WELL CHLORINATION O DESTRUCTION f . �y : <br /> PUMP INSTALLATION WELL ABANDONMENT� OTHERf , <br /> PUMP REPAI R[p-- # P1 MP REPLACEMENT';. ; <br /> DISTANCE TO NEAREST: SEPTIC TANK � <br /> f SEWER LINES <br /> SEWAGE DISPOSAL, IELD PITPRIWY <br /> CESSP OL/SEEPAGE PI OTHER l <br /> PROPERTY LINE�g,PRIVA E OMESTIC WELL PUBLICD ME5TIC EV�'L!. <br /> ,_.INTENDED USE _ <br /> Industrial TYPE OF. ID <br /> CONSTRUCTION SPECIFICATIONS <br /> v Domestic/privatex CabTe; TooT Dia. of Weil Excavation ro <br /> Domestic/public �lledDia. .of Well Casing I <br /> _Irrigation _-___Driven Gauge`of Casing L <br /> _•____`Cathodic Protection ---bra<vel Pack Depth of Grout Sea o . <br /> Disposal __!r=�R ota ^ Type of Grout , � k <br /> —�_ . Geophysical — Wither <br /> Other Information ! <br /> PUMP INSTALLATION: Conty1 `Surface Seal'A nsta e b ; <br /> Contractor . , <br /> Type of Pump Aad <br /> PUMP REPLACEMENT: "rs ems- �. ..rxor,a, . <br /> O State Work Done <br /> PUMP"REPAIR: `�.} <br /> ❑State Work" Done} <br /> DESTRUCTION 'OF WELL; Well Diameter de,67 <br /> Approximat Depths' p <br /> " <br /> Describe Materia and rote ure <br /> C • . l <br />[ .hereby <br /> Y certify that I have preparedthis app1ication-ar�d}th t the war ' •► <br /> vith Sari Joaquin Couninct <br /> ty Ordinances, State; Laws , and Rules and Re u <br /> fealth. District.. Home owner or licensed agent's signature cert` k w�TT be done in Joaquin <br /> accL lal' <br /> "I certify that in the performance of the work for which 9 Tst he of the San,Joaquin Local' <br /> fees the following: . <br /> not employ any person in such manner as to become subject Workmanermit �s Comuen ; I, shall <br /> laws_of .California. " p sation <br /> WILL CALL �FORGOUT INS�PECTI�OPRIOR �OGOUTING AND A FINAL INSPECTIONIGNED <br /> DR W PL T P N ONTREVERSE S DATE �Z z <br /> - I!E <br /> 1ASE FOR EP RTM NT USE ONLY <br />'P IL C TA ION ACCEPTED BY - <br />)DITIONAL COMMENTS: <br /> DATE <br /> PHASE II GROUT INSPECTIO <br /> SPECTION BY DATE PHASE III 'FINAL ZNSPECTIO <br /> 14 26 Rev. 9/78 INSPECTION BY.' DATE , <br />