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SAN JOAQUIN LOCAL HEAL1H M,IKill <br /> FOg FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.ir- �l <br /> - { Telephone: (209) 466-6781 � , <br /> . Date Issued iz 4. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 41 <br /> This Permit Ex fres 1 Year From Date Issued k <br /> Complete In Triplicate <br /> Application is hereby made to l he San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This ,application is made.-in compliance .with San <br /> J <br /> oaquin County Ordinance No. 1862 and the Rules and Regulations of. the San. Joaquin Local Health <br /> nistrict. y <br /> EXACT STREET. ADDRESS CITY/TOWN <br /> Owner's Name . [1'1 Phone <br /> Address <br /> - C i ty 24 <br /> License# c Phone - r a <br /> Contractor' s Name - - z <br /> 'S CERTIFICATE OF WORKt1AWd i C4"-14kSATIO"! I"SSURANCE ON FILE VlITIi SJLHD? YES N0: <br /> TYPE OF WORK (Check) : NEW WELLt�A "'DEEP EN ❑ RECONDITION C] DESTRUCTION CI Q. <br /> - - �• --WEtLL CHLORTNA-T-ION-❑ ---WEL--L=ABANDONME-NT-CI-=--OTHER F3--- <br /> --v PUMP INSTALLATION,' PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> L 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK %bo`y SEWER LINES . PIT PRIVY ( <br /> SE�AGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PITA ` OTHER <br /> PROPERTY LINE_- PRIVATE DOMESTIC WELL 14)" ---- PUBLIC DOMESTIC WELL . <br /> INTENDED USE_ :P` TYPE``OF WEI*L CONSTRUCTION SPECIFICATIONS <br /> Industrial :. }, w � ble Tool— Dia. of Well Excavation <br /> _Domestic./private Dia. of Well Casing <br /> Domestic/public ' Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection - Rotary Type of Grout <br /> Disposal Other` Other Information <br /> Geophysical F Surface Seal Instal ed b <br /> PUMP INSTALLATION: Contractor - -4- ` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done 1 <br /> PUMP REPAIR: QState Work Donee a <br /> DESTRUCTION OF WELL: Well Diameter h`'i Approximate Depth <br /> Describe Materia -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,:i_n_the performance of the work for which this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. " ' � t �# <br /> I WILL CALL FOR A GROUT -INSPECTI.ON,.-PRIOR TO GROUTING AND A FINAL INSPECTION. i <br /> DATE: (0 <br /> SIGNED - <br /> TITLE: � <br /> �URAW ,PUOT PLTN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br />' ADDITIONAL COMMENTS:_`' <br /> PHASE II. GROUT INSPECTION - - - - �- --- PHASE IZI INAL -iNSPECTION - <br /> INSPECTI,ON BY DATE - INSPECTION BY DATE <br /> 2M <br /> 4 ru I nOc o.,.. 1'7_77 <br />