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NO <br /> iALN <br /> .�_-. . pAQUIN LOCAL xtocktaDISCA095205 �` <br /> . No <br /> 1601 E. Hazeltan�Ave. a S ' -466..,6781 AI ' <br /> ' Date Issue <br /> FFIC >t1SE: :e�ephone: (209) <br /> ON FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> APPL.ICATI �. <br /> (complete .Tn Triplicates. <br /> a permit' to construct 0 <br /> made to the San Joaquin Local Health District or fiance with San <br /> Application is hereby application is made in comp a <br /> Rules an_dRegulations of the .San Joaquin Local Health <br /> #nd/or install the workhNo.herein <br /> Rul s <br /> ;Joaquin County OrdinanceCITY/TOW <br /> District. <br /> EXACT STREET ADDRESS Phone <br /> . wY <br /> Owner's Name .City. <br /> Address . .S` License Phone -� <br /> _ O <br /> ' <br /> to Name Dame ; 0 <br /> TIFICATE OF WO COMPENSATI01•! INSURA"1 ON FILE WITH SJLHO? YES <br /> IS CER <br /> RECON <br /> Checrl DESTRUCTION C) <br /> ` k) : NEW WELL U9 DEEPEN ❑ T ❑ OTHER(3�TYP1~ OF WORK ( WELL CHLORINATION Q WELL ABANDONMENTI[3 <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0 PUMP REPLACEMENT❑ <br /> SEWER LINES -F�PIT PRIVY <br /> ISTANCERTO NEAREST: SEPTIC TAN I( � + CE5SPOOL/SEEP.P�GE PI OTHER <br /> . . SEWAGE DTSPO�RJ <br /> FIELD} <br /> PROPLRTY--LIN PRIVATE DOMESTIC WELL - PUBLI DC OMESTTC WELL <br /> _aT v CONSTRUCTION SPECIFICATIONS <br /> "INTENDED USE , -TYPE; OF-WELL r� <br /> Industrial Gable Tool <br /> a-."'Of Well Excavation ►4 _ <br /> Domestic/private Drill ed._, „�,.,.. .-Dia..-Of Well Casing <br /> ' . ~ ' Dri ven Gauge-of Casing ` <br /> Do►nesti c/publ i c �-•--- <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> �- Rotary Type of Grout ---� ---- <br /> Cathodic Protection Other Information <br /> Disposal <br /> - other <br /> Geophysical - -- Surface Seal Insta ed b <br /> PUMP INSTALLATION: Contractor H7P. <br /> Type ofP Pump ------------- <br /> RPUMP REPLACEMENT: ❑State. Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter i Approximate Depth__ ' <br /> r <br /> Describe .Material and ure <br /> a <br /> I hereby certify that 1 -have prepared this application and that the work will be done in accoi <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulations of the.,_San Joaquin t <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. " w <br /> I WILL .CALL FOR R 0 CTION PRIOR TO GROUTING AND A`FINAL INSPECTION. <br /> SIGNED - . TITLE: ,v DAVE: 2 <br /> kUKAW PLUI PLAN ON REVERS I E <br /> R <br /> DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY � DATE �^ <br /> ADDITIONAL COMMENTS: <br /> : _PHASE II GROUT INSPECTION - PHASE III FINAL INSPECTION i <br /> INSPECTION BY DATE "' sy INSPECTION'BY DATET�,)2L, <br /> EH 14 26 Rev. 9/7 - '-_ 9/78 <br />