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SAN JOAQU�IN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , St CW Permit No. `s L2-2? <br /> Telephoner (20. 8 <br /> APPLICRTION FOR WELL CONST Oall R PUMP PERM Date issued 7-1 <br /> : .: 13 1979 <br /> (complete . In Tripl`.i cae�} <br /> Application is hereby made to the San Joaquin Local a ermit to construct <br /> and/or install the work herei-b 'described. This applic compliance with San c C0 <br /> Joaquin County ,Ordinance No. 1862 and the' Rules and Regulations of the San Joaquin Local Health v <br />' District. <br /> EXACT-STREET ADDRESS Vt CITY/TOWN <br /> Owner's Name „�1 a ,�. Phoney <br /> Address / F v <br /> City��a�E�u <br /> :Contractor's Name �' ,r-4,- License# Phone- <br /> IS CERTIFICATE-OF WORKMAN'S CSOMPENSATION TNSURAN4 ON FILE WITH SJLHD? YES No <br /> TYPE OF WORK (Check)-: NEW WELL C,� DEEPEN ❑ RECONDITION DESTRUCTION M r� i <br /> + WELL CHLORINATION [] WELL ABANDONMENT p OTHER (, II <br /> PUMP -INSTALLATION 0 PUMP REPAIR O PUMP REPLACEMENT E3 <br /> DISTANCE TO NEAREST:- ; -SEPTIC�JAN 0 SEWER LINES, - PIT PRIVY— <br /> SEWAGE�;DISPOS <br /> RIVYSEWAGE�;DISPOS AL. IELD CESSP OL/SEEPAGE IT� OTHER <br /> PROPERTY f <br /> LINED-(PRIVATE DOMESTIC �WELL� PUBLIC .DOMESTIC WELL <br /> ' .INTENDED11SE!�� TYPE OF WELL: . <br /> Industrial CONSTRUCTIQN SPECIFICATIONS <br /> Cable Tool ' Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ri. <br /> —Domestic/public Driven Gauge of Casing . <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection , Rotary Type of Grout v <br />__�_____ Disposal Other Other Information <br />�rGeophysical, Surface Seal Installed by: � /A <br /> it <br /> PUMP INSTALLATION: Contractor <br /> Type ofPump <br /> H.P. <br /> PUMP REPLACEMENT-: ❑State Work Done _ <br /> PUMP REPAIR: Q State Work Done , <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 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: <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 GR -UT 5PE _TJeN PRIOR TO GROUTING AND A FINAL INSPECTION. _ <br /> SIIGNED - TITLE: „c DATE: _--- +� <br /> • ' , D P N ON REVERSE I E <br /> ' FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> VP-P—VNATION ACCEPTED BY .. <br /> 4DDITIONAL COMMENTS: s -DATE -5 <br /> x <br /> el <br /> - --PHASE II GROUT INSPECTION / .PHASE IIT E NAL INSPECTION <br />;NSPECTION SY DATE <br /> INSPECTION BY ,l DATE /1 7� <br />:H 14 26 Rev. 9/78 Q - S . 7/�.� ,�,.,_ n 1 J_...J._ .f M-7o- 1)W'-- <br />