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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , .4.t ton,, CA 95205 Permit No. 7r 66Z <br /> Telephone: (209) 466-6781,: <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> (Complete In- Tri p1 i cate). .. <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 Regulations of the San Joaquin Ldcal Health <br /> District. <br /> EXACT STREET ADDRESS () "'. CITY/TOWN_S'7�`� <br /> ?_ f�• l L 1� Phoned 1 - 5�5 S S'- <br /> Owner's Name _—._.. <br /> Address 'City S140e I10-o 1i <br /> Contractor's Name&0 u 1,ov s CJ4 VUA b- L)iti#-L#k &Li cense#_ 11 Z3 Phone 3 8 - `1'6'7 <br /> .IS CERTIFICATE�OF WORKMAN'S COMPENSATION INSURANCE ON FILE- WITH SJLHD? YES 0 <br /> TYPE OF WORK (Check) : NEW WELUR, DEEPEN ❑ ' RECONDITION 0 DESTRUCTION ri <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ( <br /> PUMP INSTALLATION t2� PUMP REPAIR❑ PUMP REPLACEMENT <br /> bISTANCE TO NEAREST: SEPTIC TANK/S'0 I SEWER-LINES/i)k--;- „PIT-,-PRIV-Y—VON+E`-"'""� <br /> SEWAGE DISPOSAL FIELDVo CESSPOOL/SEEPAGE -PIT #-NE OTHER �VoN� Y "o <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL A PUBLIC DOMESTIC WELL aN9 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4 •' <br /> Industrial '.-;-�Cable Tool Dia. of We Excavation la Af <br /> _Domestic/private D:r>iIIed, Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ME--Ai 77 <br /> Disposal Other Other Information �. <br /> Geophysical r 4 Surface Seal Insta eds y: 2i L_ +-_OiE P, <br /> PUMP INSTALLATION: Contractor �'# L-+-1l N <br /> Type of Pump�g;1 : - '/1cKe r '. <br /> PUMP REPLACEMENT: ❑State Work Done . <br /> PUMP REPAIR: ❑State Work Done <br />' DESTRUCTION OF WELL: Well Diameter Approximate-Depth <br /> Describe Material and Procedure <br />' I hereby certify that I- have prepared this application and that the work will be done in' <br /> 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: 5�" <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 GROUT. INSPECTION PRIOR TO GROUTING ANDA FINAL INSPECTION. <br /> SIGNEDTITLE: --�L-z�`�►-a DATE: �'� �I"`7 <br /> PLOT PLAN ON REVERSE SIDE <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 6 <br />,ADDITIONAL COMMENTS: <br /> . PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION __. INSPECTION BY DATE -?-C' SQ( <br /> 9/78 2M <br /> EH 14 26 Rev. /78 - - - - - <br />