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v <br /> SAN JOAQUIN ,LOCAE; HEALTH U15-fFt1C-i � <br /> FFICE USE: 1601 E. Hazelton A.ye:, Stocfcton, CA 95205 Permit No. � <br /> Telephone:' (:209.) 4.6.6 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued _2 ' <br /> This Per6jt 'Ex fres l Year _'FromDa e` ;Issued r" <br /> Complete In Triplicate <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 appl-icati.on' is -made„in compliance with San <br />,-oanuin County ,ordinance %,No-. 1862 and the Rules and, Regulation's of the San. .Joaquin.,Local Health <br /> District. <br /> EXACT' STREET ADDRESS ' <br /> f' CITY/TOWN. <br /> Owner' s Name Ag <br /> Phone 9- /- <br /> Address . <br /> C i <br /> Contractor's Name Licensee Phone_ / �r <br /> IS CERTIFICATE OF WORKMAN','S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES rl NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0 PUMP REPLACEMENT NIA <br />)ISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRIVY %. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ' <br /> INTENDED USE '; TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation CA <br /> Domestic/private Drilled 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 <br /> 7-Disposal Other Other Information <br /> Geophysical Surface Seal: Installed by: <br />'UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />'UMP REPLACEMENT: ❑State Work Done &Zz01r <br />'UMP REPAIR: ❑State Work Done <br /> IESTRUCTION-OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance. <br /> pith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local ' <br />'ealth District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that i.n the ,performance of the work for which this permit is issued, I shall <br /> not employ any person !'A.in such manner as to- become subject to WDrkman's Compensation <br /> laws of California.” <br /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED P ITLE: DATE: <br /> (DRAW P OT PL N ON REVERSE SIDE f ~ <br /> j; FOR EPART ENT USfL ONLY <br /> HASE I <br /> PPLICATION ACCEPTED BY ' f ,-Z,� lkr-� DATE k <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT'INSPECTION. PHASE III FINAL INSPECTION <br /> NSPEGTION BY V, DATE �.. INSPECTION BY�_ LtA DATE <br /> 1 1426 Rev. 12=77 '!I - - - 1_ /78 2M F <br />