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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> =---FOROFFIICE USE: 1601 E. Hazelton Ave.', .Stookton,• CA 95205 Permit No. _ <br /> t Tel-ephone.: (209,) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP' PERMIT Date Issued _ _2. <br /> (,Comp l ete I n Tri p l i cafe <br /> Application is hereby made to the San Joaquin Local- Health District- for :a permit to :construct <br /> and/or install ,the work her described. This application ; is made- in compliance with 'San •` <br /> Joaquin County' Ordinance No. ,1862 and the Rules and:-.Regulations `of the° San°Joaquin 'Loca�l Health <br /> Di strict. :. <br /> y x <br /> EXACT STREET ADDRESSQ �� fY f CITY/` iG'' c <br /> Owner's Name Phone <br /> Address - k , aCity. <br /> Contractor's Name ,�'`S S� Li censePhone' <br /> IS CERTIFICATE,OF WORKMAN'S COMIPENSATION INSUR MCF ON FILE WITH'SJLHD? YES r 40 <br /> t <br /> TYPE O.F WORK (Check) : NEW WELLKRINATDION <br /> EEPEN ❑ RECONDITION [n. _DESTRUCTI.ON 0. ... <br /> 4 WELL CHL 0 WELL ABANDONMENT 0 OTHER 0 m <br /> s PUMP INSTALLATION UMP REPAIR 0', PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: - SEPTIC TANK767 "SEWER LINES „PIT PRIVY " ,1 <br /> t SEWAGE DISPOSA FIELD `�CESSP OL/SEEPAGE PIT Oe-OTHER— <br /> PROPERTY LINPRIVATE DOMESTIC WELL --- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> Industrial - Cable Tool Dia, of Well Excavation Lji2 <br /> I �mestic/private <br /> I Willed Dia. of Well Casing-. ,' ' <br /> I Domestic/public Driven Gauge of Casing J42-' C. <br /> Irrigation Gravel Pack Depth of Grout•,Se'a �- <br /> 1 Cathodic Protection 4/Rotary Type of Grout �R - d-- <br /> Disposal Other Other .Information <br /> -7--7Geophysical ( Surface Seal Installed by:- <br /> UMP <br /> :UMP INSTALLATION: Contractor 0flWApt-S 1 ,� Se <br /> ' Type of Pump _5' ,his%` H. /z� <br /> i .. <br /> PUMP REPLACEMENT: []State Work Done �- <br /> PUMP REPAIR: .0 state Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an 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 foll-owing: _ <br /> • ,I certify that. in the performance of the work for which this permit is issued, - I shall <br /> 'Inot employ o anWorkman's <br /> p y y person in such manner as to become subject to Compensation <br /> } laws 'of California. <br /> ' I DILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A'FIAL' INSPECTION. � <br /> SIGNED 22--ffJ LTITLE: DATE: -� <br /> -PLT L N N 'REVER ASIDE - / <br /> PHASE I FOR EPART NT USE ONLY <br /> PPL ICATION ACCEPTED _ f _ DATE <br /> JADDITIONAL COMMENTS: <br /> PHASE If GROUT INSPECTION PHASE III ' INAL_ INSPECTION <br /> INSPECT_I:ON SY_ . _. - DATE ,� x$ ? "�" �" , <br /> INSPECTION BY DATE <br /> EH 14 26 Rev. 9/7 -�_ - __.� R " ;. <br />