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FF CE USE: SAN JOAQUIN: LOCAL HEALTH DISTRICT <br /> 1601 E., -Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466 -6781 <br /> APPLICATION, FOR WEL-L CONSTRUCTION OR PUMP PERMIT Date Issued <br /> Thies rmit ' res 1 Year From Date. Issued <br /> jj Complete In Triplicate). <br /> Application is hereby made to the i <br /> cal Health <br /> and/or install the work herein describedaquThisoappl cation District made for <br /> a permit to construct <br /> Dfstrint. ty Ordinance No. 1862 and the Rules and Regulations of the San <br /> with San <br /> D,i-strict' n Joaquin Local Hearth <br /> EXACT STREET ADDRESS <br /> Owner's Name CITY/TOWN �p <br /> Address..'. Phoned <br /> Contractor's Name City <br /> IS CERTIFICATE OF WORKMAN'S CO"4PENSATIO"! II`iSU License, �j�f� PJ�one ,7 _ <br /> RA"�10E QPd FILE WITH SJLHD?a 1iYES NO <br /> TYPE OF WORK (Check) : NEW WELL M .'.DEEPEN 0 RECONDITIONDEST <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER <br /> PUMP <br /> PUMP INSTALLATION HER s <br /> PUMP REPAIR[� PUMP REPLACEMENT Q � <br /> DISTANCE TO NEAREST; SEPTIC TANK � � � <br /> —/� SEWER L�IIESPIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PI-- <br /> PROPERTY LIN AT <br /> PRIVE DOMESTIC�WELL PUBLIC DOME1TTCRWE <br /> INTENDED USE TYPE �le <br /> ELL --__-� <br /> �Tndustrial Cab ToolCONSTRUCTION SPECIFICATIONS <br />_Domestic/private ?- Dia. of We11 Excavation <br /> � �-Dr�'T i ed <br />- ^Dome`s-t1c/pu'b1-i c-' T 4-�-�� D a ;�,of Well Casing <br /> Irriga` Ton" -� ---Gra Pack D'auge ofTGraut9Sea � + <br /> Cathodic Protection <br /> Disposal Rotary Type of Grout " <br /> � Other <br /> Geophysical Other Information —R / <br /> Surface Seal Instal ed b <br /> PUMP INSTA.LLATTON: Contractor I <br /> Type of Pump 7 F <br /> PUMP REPLACEMENT: <br /> J�State Work Done <br />?UMP REPAIR: <br /> -O State Work Done <br />)ESTRUCTION -OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Ma-teri"a . and Proce ure <br /> hereby certify that I :=have prepared this application and that the work 'will <br /> be in <br /> lith San Joaquin County- Ordinances , State Laws , and Rules and Regulations of the SaneJoaquin oLocale <br />'ealth District. Home owner orlicensedagent's signature certifies tKe 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 0 : California. " ,{ <br /> WILL C.° Li FOR GROUT INSPECT <br /> TGNED I N P IOR TO GROUTING AND A FINAL INSPECTION.TI <br /> LE <br /> R DR W PLT L N ONTREVERSE SIDE --- DATE: <br /> FOR DEP R M NT USE ONLY <br /> iASE I _ <br />'PLICATION ACCEPTED BY '! �` • <br />)DITIONAL COMMENTS : DATE - 2-3` <br /> PHASE II GROUT INS�C7TO.N ! <br /> -�......_:._- .........sem.. . <br /> SPECTION BY T DATE' �-� - PHASE III FINAL INSPECTION <br /> INSPECTION SY ✓ DATE Z_- 2./- <br /> 1426 Rev I2-77 <br />