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FFICE USE 1601EAN JOAQUIN LOCAL HEALTH DISTRi l <br /> ` . Hazelton Avg. , Stockton, CA ?5205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR -WELL CONSTRUCTION OR PUMP PERMIT Date issued ���=-;�; <br /> (Complete In Triplicate) <br /> i <br /> Plication 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 /> 4 aquin County Ordinance No. 1862 and the Rules acid Regulations of the San Joaquin Local Health <br /> strict.' <br /> "CT STREET I'ADDRESS <br /> 4 ner's Name ,i CITY)"iOWN :ct., <br /> Pho;ile 2 , , <br /> CdresS f <br /> Itractor' s Name �Y # ,..,� <br /> City <br /> License , 1 Phone J <br /> CERTIFICATE OF �JQRK SAN'S CO3"iP£NSAT?0"1, INSURXfC QPJ FILE WITH SJLHG? YTS NO <br /> E OF WORK (Check) : NEW WELL Z DEEPEN ❑ RECONDITION <br /> WELL CHL R NATT.ONED WELL �..� DESTRUCTION❑ � <br /> PUMP INSTALLATION ED PUMP REPAIR❑ABANDONMENT MP REPLACEME-NT ❑THER 0 � <br />;TANCE TO NEAREST: SEPTIC TANK. U f SEWER LINTS — PIT PRIVY <br /> SEWAGE DISPOSI�a•L FIELD 3 ' CESSPOOL/SEEPAGE PIT �--B OTHER <br /> PROPERTY LINT PRIVA E JO ESTIC WE?L$0L'4-- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> Industrial "ONSTRUCTION SPECIFICATIONS <br /> Domestic Cable Tool Dia. ,)-Y Wv 11 Excavation-- /,z <br /> /private Drilled Dia. of Well Casin <br /> OEomestic' /publicD <br /> Driven Gauge of :as;�.- 4 <br />; Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotar <br /> Oispasal thery Type of Grout <br /> eaphysical --� Other Information - � . <br /> ,' Surface Seal Insta ed b •-. <br /> '"° INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> SMP REPLACEMENT: ❑State Work Done <br /> REPAIR: �i - <br /> ❑State Mork Done <br /> -STRUCTION OF WELL: Well Diameter <br /> Describe Materia l and Procedure Approximate Depth <br /> hereby certify that I have prepared this application and that the work will be done in accordanc <br /> San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin -Local- <br /> th 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 /> aws of California. " <br /> r--LlL CALL FOR,.1!A G UT I <br /> SPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> D <br /> TITLE: k DATE: ge' <br /> DR W PLOT PL N ON REVERSE SIDE <br /> DE ARTM£NT ' SE ONLY <br /> CATION ACCEPTED BY <br /> f IONAL COMMENTS: DATE -to 12-31-1-7 <br /> CTION B <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> Y DATE (a <br /> 4 26 Rev. 9/78 " ""'ia INSPECTION BY 4, DATE c, <br />