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s �r1 . SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave: , Stockton, CA 95205 Permit N07r q g <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELT. CONSTRUCTION OR PUMP PERMIT Date Issued C?J <br /> This Permit Expires I Year From. Date Issued <br /> Comp.1 ete I n. 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 the. Rules 'and Regulations of the San Joaquin, Local Health <br /> District. <br /> EXACT STREET.ADDRESS S"7�'�-~ A/ CITY/TOWN , <br /> f <br /> Owner's- Name A- .b-ro Phone <br /> Address �'/ �, ii/- / ,a e -s-�... -- Ci ty _ , <br /> - --— <br /> Contractor's Name License# 03Phone 2g7 <br /> I5 CERTIFICATE OF WORKMAN'S CSP NSATIOiI INSURAINCE ON FILE 41ITH '.SJLHD? YES NO a <br /> TYPE OF WORK (Check) : NEW WELL Ci DEEPEN CI RECONDITION C2 . DESTRUCTION O <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION PUMPS REPAIRI13 PUMP REPLACEMENT [I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY N <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL �( <br /> INTENDED USE TYPE OF WELL 'S I 'CONSTRUCTION SPECIFICATIONS ti <br /> Industrial Cable Tool Dia. of Well Excavation , <br /> Domestic/private Drilled Dia. of Well Casing � I <br /> Domestic/public Driven Gauge of Casing_ <br /> � cIrrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed by: <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump. sc ee t H.P. . <br /> PUMP, REPLACEMENT: M State;Work- ,Done <br /> PUMP REPAIR: � ( State Work Done - do <br /> A. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> a <br /> Describe Material and Procedure <br /> I hereby certify that' I have prepared this application and that the work will be done in accordance` <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 as to become subject to Workman's Compensation 1 <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPE ION P OR TO ROUTING AND A FINAL INSPECTION. <br /> SIGNED """`'�� ITLE: -- - <br /> /-,ADRAW PLOT PUAN ON REVERSE SIDE <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IJ II <br /> APPLICATION ACCEPTED BY DATE 6--rG -71' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA5E,JJI FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE .a-1 <br /> EH 1426 Rev- 12-77 - -- 1/78- - .2M <br />