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)JAN. JUAl1U1N LULAL HLALIH U1JIKIO <br /> FOR OFFICE USE: 1601 1 lazelton Ave. , Stockton, CA ! )5 Permit No.'79- z/ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR' WELL CONSTRUCTION OR PUMP PERMIT Date Issued 8-/-7 <br /> This Permit Ex i'res 1 Year From Date Issued <br /> / Complete in Trip irate <br /> aoplication is. hereby made to the San Joaquin Local' Health. District for a permit to construct <br /> ind/or install the work herein described. This application is made in compliance with San <br />'oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br />)istrict. <br />-XACT STREET ADDRESS A4Io, o (,Uye tYGIa ' u CITY/TOWN <br />)wner' s Name Q .%� A4r C�,�' Com. . __ _ Phone$3 i 1 <br /> address %lbE ST City • -/ <br />:ontractor' s Name Licensel(3yj,3z—_'� Phone 'moi% (viz- / <br />'.S CERTTFTCATC 0 WORKHAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WEAL❑ DEEPEN 0 RECONDITION Q . DESTRUCTION❑ � <br /> WELL CHLORINATION :WELL ABANDONMENT 0 OTHER (] k <br /> PUMP iN§TALLATION,� PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br />)ISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE- PRIVATE 66MESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' Cable Tool Dia'. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> D •'- <br /> Domestic/public,,' Driven'- Gauge of`Casing <br /> Irrigation . t Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary . Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instaa Ted by. <br />'UMP INSTALLATION: Contractor �* <br /> Type of' Pum H• • <br /> SUMP REPLACEMENT: ❑State York Done <br />'UMP REPAIR: i • <br /> p State Work Done <br />)ESTRUCTION OF WELL: Well Diamet$r' Approximate Depth <br /> Describe Material and ProceTu_rer <br /> I hereby certify that I have prepared this application .and that the. work will be done in accordanc <br /> vith San Joaquin County Ordinances-, State Laws , and Rules and Regulations of the San Joaquin Local <br /> iealth 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." r <br /> Q WILL CA R A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> NIG D TITLE: DATE: �4%ZY-79 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F. FOR DEPARTMENT USE,ONLY, <br />'HASE I <br /> PPS LIGATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY. ' )! DATES ;• 72 <br /> ..,l ., ... C.l�,l / 7P W <br />