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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit Not-191,-,Jn <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued '7=11- <br /> This Permit Expires 1 Year-From Date Issued ' <br /> Complete In Triplicate <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 Rules and Regu ations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRES J/ CITY/TOWN —, <br /> Owner's Name Phone <br /> Address Ci-ty- <br /> Contractor's Name Phone_ -Z�U3� <br /> IS CERTIFICATE OF W KHA'N'S COMPEN ATIOM INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELD. --- DEEPEN ❑ RECONDITION ❑ - DESTRUCTION❑ 9-) <br /> WELL CHLORINATIQN_❑ WELL ABANDONMENT p OTHER ❑ �j <br /> PUMP INSTALLATION❑ PUMP, REPAIR❑ PUMP REPLACEMENT [� <br /> j z <br /> DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD i CESSPOOL/SEEPAGE PITO OTHER ; <br /> PROPERT;Y- LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE' TYPE OF WELL CONSTRUCTION SPECIFIC,TA085 <br /> Industrial R Cable Tool Dia. of Wel-rl -EXcavation <br /> Domestic/private Drilled Dia. of Well Easing <br /> Domestic/public DrivenGauge of/Casi'n I <br /> Irrigation € Gravel Pack m Depth offGtout--Seal <br /> Cathodic Protection Rotary Type of •G,rout € <br /> Disposalthey Other Information € <br /> Geophys-ill Surface ;8"e-al Instal led: <br /> PUMP INSTALLATION: Contractor <br /> F Type of Pump �' i i H`.P: <br /> , <br /> PUMP REPLACEMENT. ❑State Work Done l E <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter N.Approximate Depth <br /> Describe Materia and-Proced ure Z_ !_ <br /> f ' <br /> I hereby certify that I have prepared this application and that t*.,*o'rk will be done in accordancef <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 per.formance ;of the work for w is permit is issued, I shall <br /> not employ any :person in such ',6a'hner as to beco subject Workman's Compensation <br /> laws of C lifornia." f -� ------ -- 1, <br /> I WILL CAL F R A GROUT INSPECT 'PRIOR T0,4GROUTIN ANDA FI INSPEC I <br /> SIGNED l 'Y TITLE: ; TE: <br /> DR W RLO „ L N ONREVS _SID,E- <br /> FOR DEPA MENT USIE ONLY <br /> PHASE ;I f r <br /> APPLICATIDN ACCEPTED 8Y DA <br /> TE �7 <br /> ADDITIONAL COMMENTS : <br /> PHASE ,II GROUT INSPECTION " r"r` --PHASE-III`"FINAL INSPECTION <br /> INSPECTION BYDATE _ �, INSPECTION BY DATE <br /> EH 1426 Rav_ 12-77 ' T 1 /78 2M <br />