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v/ SAN JOAQUINz,,LOCAL,,r;HEALTH DISTRICT
<br /> FSE USE: 160] E. Hazelton;.Ave; S;toc�kton, CA 95205 Permit
<br /> Telehole:
<br /> ,p k_ {.209) 4;66-6781
<br /> APPLICATION FOR WELL CONSTRUCTIONORPUMP PERMIT Date Issued_S-
<br /> � Y .: f x_7 'i [ . -,� � ,fit
<br /> This Permt t.. Ex i res 1 Year "From ,Date ,Issued
<br /> Complete n
<br /> ITri pl i cafes f 03 / ,
<br /> '2,,.! ! Y?7-tz3 �' F
<br /> Application is hereby made to the San Joaquiri. Local Health .Dt.,stri.ct .,for ,a' permit-!to-,construct t
<br /> and/or ivnstall'(the ,work herein dos cr.,ibed '- Jhis,appli,cattom.1s made , .Gompl.j ance w:i,th..,San
<br /> Joaquin County",�Ord:i,nance No..� 1862.:and the ;Rul eSr- nd. Regul atJons sof the. Sari--Joaqul n;r Local•..Neal th
<br /> District.
<br /> ` "� �.d✓�ror� r },
<br /> EXACT `S`TREtT ADDRESS ` � '_6�/ .. +GCL _ a CITY/TbWN i f
<br /> Owners Name _„ - n
<br /> t Poet f
<br /> Address
<br /> Ci.ty
<br /> Contractor` s Name �l Sf� / flA ' ' / F License# �Phone_16"F-3 7
<br /> IS CERTIFICATE. OF WORKMAN'S COMPENSATIO'! INSURA'dCE ON FILE, WITH SJLHD7 YES f40
<br /> -- _—W °RECONDITION = DESTRUGT . 1[�-0
<br /> TYPE QF WORK _(Che.ckNEW ,WELL_�_� .C3EEPEN CI
<br /> £CL CT4_C INArO_V [ WEU1 ABAND0T4MENT-0 H
<br /> PUMP INSTALLATION 0 PUMP REPAIR 0 POMP REPLACEMENT [I
<br /> F
<br /> DISTANCE TO NEAREST: SEPTIC TANKy1G`,0 SEWER LINESv7 PIT PRIVY -•-�-- _,___
<br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER e
<br /> PROPERTY LINE. PRIVATE DOMESTIC WELL -/-W- PUBLIC DOMESTIC WELL -
<br /> I:NTENDED USE TYPE OFIWELL CONSTRUCTION SPECIFICATIONS
<br /> Industrial Cable Tool Dia. of Well Excavation
<br /> Domestic/private Drilledm Dia. of Well Casing ;
<br /> Domestic/public Driv6h Gauge of Casing
<br /> Irrigation Gravel.' Pack Depth of Grout Seal
<br /> Cathodic Protection Rotary Type of Grout _, -�►�,,�, � v
<br /> Di sposall. Otheri� Other Information
<br /> Geophysical ' Surface Seal Instal ed by: ;.,_,_•
<br /> PUMP INSTALLATION: Contractor
<br /> i r
<br /> Type of Pump_
<br /> PUMP REPLACEMENT: []State Work Done
<br /> PUMP REPAIR: : []State Work Done
<br /> DESTRUCTION OF,WELL:,,,. Well .Diameter I t Approximate Depth
<br /> Des:cri-be-Materi-al-an -Proce_ ure-
<br /> I hereby certify that I have prepared this;application and that-,the-worrk-wi-1 l-be-.done in accordance.
<br /> with San .Joaquin County Ordinances , State Laws, and Rules and ilRegulations `>of/jhe San Joaquin Local
<br /> Health District. Home owner or licensed agent' s_signature—cer.,ti;fies the foT�l`owing:- l
<br /> "I certify that in the performance of the work fb` 9which t s permit is issued"'I shall
<br /> not employ, any person in such manner as to become subjectlto Workman's Compensation ;
<br /> 1 aws of California. " '
<br /> I WILL CAL FOR A GROUT INSPECTION PRIOR-/TO GROUTING AND A FINAL INSPECTION.
<br /> SIGNED 1%`'`. ` TITLE: d DATE:
<br /> DR W PLOTi PLN ON REVERSE SIDE
<br /> FOR DEPARTMENT USE ONLY
<br /> PHASE I
<br /> APPLICATION ACCEPTED BY DATE
<br /> ADDITIONAL COMMENTS: � �
<br /> PHASE II. GROUT INSPECTION. r PHASE III FINAL INSPECTION
<br /> INSPECTION BY_,,-,/,j DATE INSPECTION BY DATE
<br /> D�
<br />:H 1426 � Rev. .12-77.w.. _.... _/-.. 1,17A 9M I
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