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SAN JOAQUIN LOCAL HEAE T,H 0I5TRICT <br />_ FOR OFFICE USE: 1601 E. Hazelton Ave. , fAock�n, CA 95205 Permit No. 79_ia.44 <br /> Telephone: (2�6?9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -8-19 <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District fora permi..t to construct <br /> and/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 /> "District. <br /> EXACT STREET ADDRESS lCITY/TOWN 4 <br /> Owner's Name S Phone(,,"? 7- 7.3 - } <br /> Address13 <br /> [/ City -- <br /> Contractor's Name r La cense# .3 go Phone1170 <br /> 'S CERTTFICATE OF WORKiIAN'S COFIPENSATIOIN INSURAFJCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF t46_K(C7ieck) NEW WELL[9 DEEPENO RECONDITION CD DESTRUCTION 13 <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 29 PUMP REPAIR❑ PUMP REPLACEMENT C❑ <br /> DISTANCE TO NEAREST: `'SEPTIC TANK-,h rt'e SEWER LINES,,,;,.,e- "PIT PRIVY ,..) <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> _ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE i TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ C Cable Tool Dia. of Well Excavation , <br /> k; Domestic/private Drilled Dia. of Well Casing_ <br /> ! - Domestic/public Driven Gauge of Casing <br /> Irrigation l _ Gravel -Pack, Depth of Grout Seal "p <br /> Cathodic Protection Rotary . t Type of Grout 9,:r -sg C( _ <br /> Disposal Other ' Other Information <br /> Geophysical - ti Surface Seal Installed by.U4,4A <br /> PUMP INSTALLATION: Contractor"- <br /> Type of Pump r H.P. <br /> PUMP REPLACEMENT: State Work Done 7 <br /> PUMP REPAIR: - Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordancOI <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 f <br /> laws of California." i <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> f <br /> SIGNED TITLE: DATE: $' 4 <br /> DR W PLOT PLIN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL`INSPECTION <br /> INSPECTION BY DATE_ 3-1-z-,?!? INSPECTION BY C DATE -3 - <br />