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11 <br /> /C SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> _ F IC USE ' 1601 E. Hazelton ,Ave.., Stockton, CA 95205 Permit No. <br /> J 1. Telephone: - (209) 466-6781 <br /> APPLICATION FOR WELL-CONSTRUCTION OR PUMP PERMIT <br /> Date Issued 5J 71 <br /> This'-Permit Ex i.res. 11 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 '0rdinance No. 1862 and -the Rules and Regulations of the San Joaquin.- Local Health <br /> District. [*� �r ii1 "lFrLD��c ✓ .y est A4J0/,0,/-x 0 two �-6 -53,0-4, <br /> CITY/TOWN <br /> EXACT STREET ADDRESSo� �'" �` `��` ITOWN <br /> Owner's Name . ; Phone <br /> Address Via.• y7%,. t ?i City �S'c <br /> Contractor' s Name-alft, _ Li cense# hone_ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES N0- <br /> TYPE- OF- WORK <br /> TYPE- OF WORK (Check) : NEW WELL❑ DEEPEN ❑ . - RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION 0 PUMP REPAIR P6 PUMP REPLACEMENT [A � <br /> DISTANCE 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 /> 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%publ-it- " Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection - Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical . Surface Seal Installed by: <br /> r PUMP INSTALLATION: Contractor ` <br /> Type of Pump H.P. <br /> M PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: DO State' Work Done • <br /> ` DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I haveiprepared-this -application and that the work will be done in accordant( <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> k 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 California." e <br /> I WILL CALL FOR A GROUT INSPECTION P R TO. ,GR6 TING AND A FINAL INSPECTION. <br /> ' <br /> SIGNED <br /> DATE: <br /> a <br /> DR L T =PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> F PHASE I DATE ! S5 " <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY O� DATE INSPECTION BY DATE_ <br /> FN 1 a9h ap„ T9_77 __ 631/78- , 2M_ <br />