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` SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , .Stockton, CA 95205 Permit No. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issuedjj <br /> This Permit Ex ires 1 Year From Date. Issue'd' <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 Ordinance No. 1862 and the Rules and Regulati-ons of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY%TOWN r <br /> r <br /> f Owner's Name m s ra Phone <br /> Address S r r u1 City <br /> k Contractor' s Name rLicense# o Phone <br /> f <br /> IS CERTIFICATE OF WORKMAN-S COMPENSATIO+"! TINSURAINCE ON FILE WIT11 SJLHD? YES ;¢O <br /> TYPE ' OF WORK (Check) : NEW WELL L DEEPEN ❑ RECONDITION DESTRUCTION* <br /> R <br /> WELL CHLORINATION WELL ABANDONMENT 0 OTHER <br /> PUMP INSTALLATION PUMP REPAIR O PUMP REPLACEMENT �} <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL R PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFI <br /> ' Industrial CATIONS <br /> Cable Tool Dia. of Well Excavation <br /> (`Domestic/private Drilled Dia. of Well Casing (� <br /> �. Domestic/public Driven Gauge of Casing RU <br /> Irrigation _Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other, Information <br /> Geophysical Surface Seal Inst—a led by: <br /> PUMP. INSTALLATION: Contractor <br /> Type of Pump c <br /> N.P. iA <br /> PUMP REPLACEMENT: Q State Work Donee <br />' PUMP- REPAIR: ❑State Work Done <br /> fDESTRUCTION"'OF WELL: Well Diameter <br /> Describe Materia and Procedure `�`� k' _ ' Approximate Depth b <br /> 1 ts O f ra <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 W <br /> 'laws of California. " J Workman 's Compensation <br /> I WILL CALL FORA G UTINSPECTION PRIOR TO GROUTING AND A FINAL INSP CTION. <br /> SIGNED o TITLE: DATE: <br /> R W PLT L N ON REVERS IDE f <br /> PHASE I FOR DEPARTMENT-0-SE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATFz/.' � <br />,EH.I42F;..._ Rpt►. -12-77 r - IE <br />