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SAN JOAQUIN LOCAL HEALTH DIS1RiCf Per No. <br /> FFICE USE: 1601 E. Hazelton �1veStoc6o6gA 95205 <br /> Telephone: (209} Date I ssued �- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires l` Year From Date Issued. <br /> € Complete In Triplicate) . .. <br /> t <br /> ct <br /> str <br /> Aopl7cat7o <br /> n is hereby made }to -the San Joaquin Local Health Distmade inrcompliance withnSanuct <br /> arid/or install' the work herein] described. This _app.lication - <br /> unt Ordinance No. I862 and the Rules and Regulations of the San Joaquin Local Health <br />."oaquin county <br /> District. CITY/TOWN } <br /> EXACT' STREET ADDRESS phone <br /> f . <br /> Owner' `s Name City <br /> Address L_ <br /> License Phone <br /> Contractor' s Name <br /> *� NSURA"�aCE I FILE WITH SJLHD? YES <br /> ':S CERTIFICATE OF WORKMAN'S. COMIPENSATIO I <br /> TYPE OF WORK (Check) : NEW WELL <br /> DEEPEN ❑ RECONDITION C:2 DESTRUCTION <br /> C1 oQ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER <br /> ~ I,NSTALLATION CS PUMP REPAIR❑ PUMP REPLACEMENT Q e <br /> PUMP - . ,V <br />` DISTANCE TO NEAREST: SEPTIC TAN_ SEWER LINE PIT PRIVY <br /> SEWAGE DISPOS L FIELQ <br /> t C S L/SEEPAGE PIT ..-- OTHERS r <br /> PROPERTY LINR�0�'EPRIVATE DOMESTIC WELO� PUBLIC DOMESTIC WELL' . <br /> TYPE OFWELL CONSTRUCTION SPECIFICATIONS <br /> f INTENDED USE Dia. of Well Excavation ' <br /> Industrial Cable Tool <br /> Domestic/private Drilled T 3 =`` Dia._of Well Casing_ <br /> Driven Gauge of Casing <br /> j <br /> Domestic/publicGravel Pack '' Depth of Grout Seal, <br /> �Irri ation '' <br /> Cathodic ProtectionRotary "Type of Grout }. <br /> Disposal Other , Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION:— -Contractor. H. . <br /> Type!�of Pump F ; <br /> PUMP REPLACEMENT: State Work Done • <br /> PUMP REPAIR: b8tate Work Done ; , • . <br /> 3 Approximate Depth. , <br /> C DESTRUCTION OF WELL: Well Diameter r <br /> "Describe Materia and Proce ure <br /> this app <br /> lication and that the work will be done .in accordan <br /> I hereby certify that I have prepared <br /> 4 with San Joaquin County Ordinances , State Laws ,':and Rules and Regulations of the San Joaquin Lova <br /> Health District. Home owner - <br /> formanceSof the worksforawhichcthisfpermities eisoissued, I shall <br /> I <br /> certify that in the per <br /> not employ any person in such manner as to become subject to Workman' s Compensation. <br /> r <br /> laws of California." �I <br /> � 1 <br /> I WILL CA R A GR UT SP ON PRIOR TO,_GROUTI.NG_AND AFINAL INSPECTION• DATE: / <br /> f. SIGNS � TITLE: e, <br /> F DR PLOT :PLN ON REV S SIDE <br /> FOR DEPARTMENT USE ;ONL'Y� <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: �_ z.— PHASE III- FINAL INSPECTION <br /> --- PHASE .T--GROUT INSPECTION DATE1 <br /> 4; 'INSPECTION BY <br /> F INSPECTION BY I/7$ <br /> - - �- n -77 20o <br />