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SAN;.JOAQUIN LOCAL HEALTH DIS-SRICI � <br /> FFICE USE: ✓ 1601 E. Hazelton Ave. , -Stock4on, CA 95205 Permit No. Zg Vis-/ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL .CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires I Year From Date Issued. . <br /> Complete In Triplicate) ' <br /> Application is hereby made to the San Joaquin Local 'Health District fora 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 /> Di's tr1ct. <br /> EXACT STREET ADDR S �3' 0 c.Ja.� 6 CITY/TOWN Lam! <br /> Owner's Name �' Phone 3 <br /> Address ° r 9 iCity i <br /> Contractor's Name fa- L2 1 <br /> ' :` Licensee Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> F <br /> TYPE"OF-WOR-K -(Check):''NEW-WELL DEEPEN ElRECONDITION ❑ 'DESTRUCTI-ON❑ <br /> WELL CHL R ATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK z tv`0 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD zyo'f CESSPOOL/SEEPAGE PIT2oa'f OTHER �- <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 01 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIE CAT NS € <br /> Industrial Cable Tool Dia. 'of Well Excavation <br /> Domestic/private Drilled Dia. of Well 'Casing <br /> Domestic/public Driven Gauge of Casing /17 <br /> IrrigationGravel Pack Depth of Grout Seal 1 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. Other Other Information di <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DEST-RU-CTI-ON OF. WELL: Well Diameter-,.. Approximate-Depth - <br /> Describe Material an2 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 <br /> laws of California." <br /> I WILL CALL FOR A T INSPECTIO PRI OUTING AND A F NAL NSPE TION. r� <br /> SIGNED a TITLE: DATE: 7 a <br /> DR PLOT PL N ON REVERS-E 5TDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY. <br /> , <br /> APPLICATION ACCEPTED BY_ DATE f—,11— � <br /> ? <br /> ADDITIONAL COMMENTS: v�' <br /> PHASE IIGROUT INSPECTION PHASE III FINAL INSPECTION _ <br /> INSPECTION 8Y ��r. DATE 7— <br /> INSPECTION BY DATE <br />:'N 7 a9k Ontr 19-77 1 /7R 'SNP 3 <br />