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•FFICE USE: SANWJOAQUIN LOCAL. HEALTH DISTRICT <br /> -- � 1601 E. Hazelton Ave. ;:S!NAOR .P <br /> on, <br /> f 205 Permit No. <br /> f` Telephone: '7 9-x'1' - <br /> g' APPLICATION FOR WELL CODate I <br /> M P T. .: ssued7� <br /> This Permit Ex fres ear <br /> Complete In Trip icate ssued <br /> Application is hereby made to the San Joaquin Loc�Alb,�,�Q <br /> acid/or install the work herein described, This app <br /> Joaquin County Ordinance No. 1862 and ed. . Tl tI��ALfor. a permit to construct <br /> i n: Compl.i ance with San <br /> Cistrict. es and Regulations of the San Joaquin Local Health <br /> f EXACT STREET ADDRESS <br /> R Owner's Name CITY%TOWN Q... <br /> Address 3 - Phone <br /> Contractor' s Name City <br /> .S License# 4 z Phone <br /> _'S CERTT'rICI�TE OF 1JORK"SAtd'S CO"'PENSA'TTO"1"I JSURA"}CE' OPJ FILE WITH SJLFiD? 3 <br /> rTPE-OFu.WORK` Check -RECONDITION <br /> _ YES <br /> NEW WE�C DEEPEfV CCS `REC DITIO Q" DESTRUCTION EJ x � - <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER � <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE ,TO NEAREST: SEPTIC TANK, j <br /> SEWAGE DISPOSAL,FIELDER LINES PRTVYPIT�S <br /> � <br /> PROPERTY LINE`S,PRIVATE DOMESTIC WELLSE--.� E OTHER <br /> INTENDED USE PUBLIC DOMESTIC WELL <br /> ndustrial TYPE OF WELL CONSTRUCTION -SPECIFICATIONS . <br /> Domestic/private - —Cable Tool Dia. of Well Excavation # <br /> _ _ DomeStic/public�"" Drilled ti- '`"t-Dia, of-:-Well Casing <br />-—_.:I rri gat i on ---tri vn - ^Gauge ofCas n <br /> gal <br />.��Cathodic Protection Rota r.Gravel Pack Depth of GroutSeal <br /> - <br /> Disposal y ' Type of Grout <br />�Geophysical Other Other Information <br /> Surface Seal Instal lecl b <br />'UMP INSTALLATION: Contractor <br /> Type of Pump <br /> .S <br />'UMP REPLACEMENT: one� . • <br /> �]State Work D �` <br />'UMP REPAIR: ❑State Work-Done <br />'ESTRUCTION OF WELL: ' <br /> _ We1iN Diametert <br /> -.Well <br /> and Procedure "App-rox-i-mate-De -the- -- <br /> hereby certify that I have prepared this aicatio <br /> ppln and that the ,;wor.k will <br /> ith San 'Joaquin Count Ordinances , 11 be done in accordance <br /> ealth District. Homeowneror licensed eagent.,'sasignatu�rees acertnd efies thesfollowof i San Joaquin Local <br /> "I certify that in the performance of the work for- whi'ch this ng' <br /> not employ any person in such manner as to'become. sub ect to Workman's Compensation <br /> shall <br /> laws of California. " pion <br /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND, AF.INAL INSPECTION. <br />'GNED I <br /> TITLE: <br /> DR W PLOT PL N ON REVERS SIDE DATE: <br /> ASE I FOR D PARTMET USE ONLY <br /> PLICATION ACCEPTED BY i <br /> DITIONAL COMMENTS:?. DATE f9 # <br /> PHASE. II ROUT INSPECTIO <br /> iPECTION BY� -DATE..; V c PHASE -III FINAL INSPECTION.. <br /> INSPECTION BY r <br /> DATE � <br /> 1426_ <br /> .Rev. ` <br />