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SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> —IF USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.V 9- Q� :. <br /> Telephone: (209) 466678.1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued_$ -15-79 <br /> (I;omp l ete In Trip l i caste) <br /> Application is hereby made to the San Joaquin Local 41 a,,J ;h District for a permit to construct <br /> and/or install the work herein described. This applica' i n is made in compTiance with .San- <br /> Joaquin .County Ordinance No. 1862 and the Rules and Rdgu tions of' the San Joaquin Local- Health <br /> District. <br /> EXACT, STREET ADDRESS OW <br /> dZ 3 3 'z- � CITY/TN <br /> Owner's Name <br /> Phone �� <br /> Address �g � ,,z <br /> City_ <br /> Contractor's Name 411-5License#30h6ne Ste. <br /> IS CERTIFICATE F WQRKMAN'S COMPENSATION INSURAKE ON FILE WITH SJLHD? YES K NO. <br /> TYPE .OF WORK_._(Check) : NEW WELL 0, DEEPEN 0 . . `RECONDIT-ION.0-- DESTRUCTION[)" <br /> WELL CHLORINATION C1 WELL ABANDONMENT 0 OTHER-0 �} <br /> PUMP INSTALLATION 0 PUMP REPAIR a- PUMP REPLACEMENT p <br /> wi <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES PIT PRIVY _ - NJ <br /> r SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE .PIT OTHER +�1 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLICDOMESTIC WEAL '- <br /> INTENDED USE TYPE OF-WELL., CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavat1on <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 t <br /> Disposal - Other Other InformO on <br /> Geophysical Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> RUMP REPLACEMENT: Q State Work Done <br /> 4 , <br /> PUMP REPAIR: 4 pState Work Done <br /> DESTRUCTION. OF WELL: _Wel.1-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 accordancl <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 subject to .Workman's Compensation <br /> laws of Cal fornia. " , <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TQ -GROUTING AND A FINAL- INSPECTION. <br /> SIGNED TITLE. DATE: / <br /> i <br /> (DRAW PLUT PL N ON REVERSE YIDEJ <br /> PHASE I F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 1�11,5-17 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI PHASE III 'f4NAL 3N5PECTION <br /> INSPECTION BY <br /> DATE /✓'� INSPECTION BY ATEA <br /> EH 14 26 Rev. 9/78 11'73Z A/7A 9 <br />