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SAN JOAQUINi LOCAL,,HE;ALTH 01S-fRICl
<br /> FOR FFIft USE: ke 1601 E. Hazelton -Ave.,,, S'foc.kton, CA 95205 � Permit No. ,3�a
<br /> Telephone:. F�42091) 4s6 7,6781
<br /> ..�. �• - RU ._; �<. _
<br /> APPLICATION FOR WELL CONSTCTION OR PUMP PERMIT Date Issued2_/-78'
<br /> . �,.§i.e,,,. ECr
<br /> This Permit:°Eic fres Y `YAr E`roiit Date sued
<br /> Complete In 7�i
<br /> . 1.;3: _?`.t';ir.�:i:J;"a` .. .> ) . _ .:, , • !-� J,:, e :`st> ,. alb.. E .:jJ�i '-_tfi': . . _.,. _ � ,
<br /> Application is herebymade to the San Joagu i,nLQca l He.;a1 thr�D str ct for•-a permit;to 3c,onstruc_t,
<br /> and/or i nStal 1 rtheY cork .h,erei.n descr.i bed This ap.pl, ,cat�ron ;i s ma-de, n com,pl #pgp with, San;: ,w.'
<br /> Joatqui n tCounty,(Ord �nance,,-I�o ,:1862.;and the„Rules=and Regp,7 at7;ans of t e. San, ,loaq�i p4 Loca Health
<br /> DistrlCt• - ^J {
<br /> EXACT STREET ADORESS- {_;,2-#yI'' 1 , S, '( SIL S' ':�. CTTYJTOWN
<br /> Owner's Name �5 Phone
<br /> Address city
<br /> Contractors Name Cj I AS o, l LAIF ( ['P1t.�_/A16 Li censef 3 '7Df)-Phone7S�3 3377
<br /> I5 CERTIFICATE -OF-14ORKMAN'S C01APE'NSATIOl'-INSURAmC_r ON FIL1 ,WITH-SJLHQ?-m" -Y'ES-- %-- NO -
<br /> --
<br /> TYPE-OF WORK-(Check) :-NEW-WELL —DEEPEN ❑=-=- RECONDITION ❑ = -DEST-RUCT1ON-S--1,�. T om-
<br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ A
<br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q.
<br /> DISTANCE- TO NEAREST: SEPTIC�TANK (p SEWER LINES & SPIT PRIVY �=
<br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER
<br /> PROPERTY LINE,25-PRIVATE DOMESTIC WELL----PUBLIC DOMESTIC ,WELL -
<br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS
<br /> Industrial �Cable Tool Dia.. of Well Excavation
<br /> i>,/ Domestic/private Drilled , Dia. of Well Casing
<br /> Domestic/public Driven Gauge of Casing o
<br /> Irrigation -77-Gravel,_ _Pacic_�-_�k -.Depth. of_G.r_out:Seal SO
<br /> Cathodi-c= Protection .;Rotary Type of Grout 54-if,-- C_
<br /> Disposal Other. �. A � Other Information
<br /> GeophysicalSu
<br /> e, �R:} rface Seal Installed by:+ `:
<br /> PUMP INSTALLATION: Contractor'
<br /> Type"of Pump H.P. '
<br /> PUMP REPLACEMENT: Q State Work Done
<br /> PUMP REPAIR: ❑St'ate Work Done
<br /> DESTRUCT ION_.OF W.ELL.:. = Wel 1-,.Diameter Approximate Depth
<br /> Descr-lbe Material an a 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 signatureNcertifies' 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 q .
<br /> laws of California."
<br /> I WILL CRL , FOR A GROUT INSPECTION PRIOR TO.-GROUTING AND A F-INAL_I.NSPECTION.
<br /> SIGNED ' TITLE: DATE;_�S
<br /> (DRAW PLOT PLN ON REVERSE SIDE �
<br /> FOR DEPARTMENT USE ONLY
<br /> PHASE I r ''
<br /> APPLICATION ACCEPTED BY DATE -- ''j -7:T
<br /> ADDITIONAL COMMENTS: '
<br /> PHASE II G OUT INSPECTION PHASE III FINAL INSPECTION
<br /> INSPECTION BY r DATE !Z— INSPECTION BY DATE�i'(
<br /> EN 1426 Rev- 12-77... .� � _ - �, _ 1/78-- �2M i
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