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46&42 �iin SAN JOAQUIN LUCAL. HEALI'H 01S I R10 <br /> EQR 60ICE CE USE: 1601 E. Hazel ton -Ave. , . Stockton, CA 95205 Perini t No,'7-3 <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP. PERMIT Date Issued 015— <br /> This <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 /> Lloanu?n County Ordinance No. 1862. and.. the Rules and Regulations of.. the San Joaquin Local Health <br />' Distri.ct. <br /> EXACT STREET ADDRESSq 73 CITY/TOWN <br />' Owner's Name Phone <br /> Address _ City <br /> Contractor's Name 9 Licensees k hone <br /> IS CERTIFICATE OF WORKMAN", COMP t TAINSUR1110E 0N. FILE WITH SJLHD? . YES 710 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ + RECONDITION ] DESTRUCTION[D <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER 0 �v <br /> PUMP INSTALLATION (0 PUMP REPAIR❑ PUMP REPLACEMENT ❑ . <br /> iDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> F INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled 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 E Other Information <br /> j Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type Sof Pump H.P. <br /> PUMP REPLACEMENT: [3 State Work Done <br /> PUMP R: ®State'Work Done n <br /> DESTRUCTION 0C'VELL: Wel"1 Diameter .-A Approximate Depth <br /> Describe Materia an .Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc <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 as4to become subject to Workman's Compensation <br /> laws of California. ' <br /> 1I WILL CALL.. OR A GROUT._..INSPECTION,4kRI0R_TQ GROUTING AND A FINAL INSPECTION. <br /> SIGNED ' c LE: � P . DATE: <br /> D PL PL N REVERSE SIDE <br /> r FOR DEPARTMENT USE ONLY <br /> 1 PHASE I -. DATE <br /> (APPLICATION ACCEPTED BY -� -- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I,11 FhNAL INSPECTIO <br /> 6 SPECTION 8Y DATE INSPECTION BY DATE g <br /> FN 119A Pov 19_77 _ 117$ 2M._ <br />