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' FF ICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. S <br /> Telephone: 5 Permit No.a 2 -816 <br /> APPLICATION FOR WELL G0 OR . U T Date Issued <br /> (Complete In TriokC4 <br /> � j <br /> r <br /> Application is he <br /> made to the San Joaquin Lo JA <br /> and/or install .the work herein described. This ap 1.for a permit to .'construct ' <br /> Joaquin` .County Ordinance No. 1862 and : a .in -compliance with San <br /> District. This <br /> and Regulations of. theSan .Joaquin Local Health <br />[ EXACT STREE DRESS <br /> Owner's Name .-CITY/ <br /> TOW - <br /> Address f Phonel�/,_� <br /> Contractor's Name � �x-19 C.i ty <br /> �p License#/ 37-Phone "�-"-- <br /> JS CERTIFICATE OF WORKMAN'S CO""PENSATIOPJ INSURA"10E 0 � � <br /> N FILE WITH•SJLHD? YES <br /> TYPE OF WORK {Check) : NEW WELL <br /> "a 0 ".=DEEPEN CxWELL RECONDITIONWELL CHLORI-NAT-10V �DEOIN oBANDONME® OTHER PUMP INSTALLATION PUMP REPAIR( " --0-- <br /> _r <br /> RUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> { I -PIT PRIVY <br /> SEWAGE DISPOSAL, FIELD.,, "CESSPOOL/SEEPAGE PIS <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL � ,_ p OTHER <br /> INTENDED USE • <br /> UBLIC D MESTIC .WEL T1 <br /> rte, TYPE OF-WELL., <br /> IndustriaT � CONSTRUCTION SPECIFICATIONS- �.. <br /> ��Domestic/private - Cable Tool Dia, of Dell Excavation <br /> Domestic/public Drilled Dia. of Well Casing '. ' <br /> Irrigation — Dri-ven . Gauge of Casing , <br /> ��Cathodc Protection -- Gravel Pack s, -Depth of Grout Sea ' <br /> dr Rotary . <br /> .LDisposal ther Type of Grout ' <br /> —.Geophysical ---_� Other Information <br /> PUMP' INSTALLATION: - Surface Seal Insta ed <br /> Contractor--- -, <br /> Type of Pump .r <br /> PUMP 'REPLACEMENT: H•P• <br /> O State Work` Done <br />"PUMP REPAIR: MS'tate Work Do <br />!DESTRUCTION"OF WELL: We1.TD.i.,amr ,�. .� -- <br /> Descri be Materia an ' : <br /> ure , TA proxam"'a e Depth-- <br /> I hereby, certify that I have'-prepared .this application and that the 1 <br /> 4ith San Joaquin County Ordinances, work will be done in accordant <br /> lealth :District; Nome owner or Tic�nsedeagent's signature certifies th <br /> sV and Rules and Regulations of the San Joaquin Local <br /> "I; certify that in the performance of -the work for which this permiteisaissu g: <br /> not employ any person in such manner as..to become subject to Workman's Compensation I shall <br /> laws of California. " <br /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTIO ~ <br /> IGNED N. <br /> TITLE: <br /> # DR W PL T L N ON REVERSE E DATE: <br /> 1ASE I R EPARTM NT USE ONLY <br />'P�LICATICN. ACCEPTED BY <br />)DITIONAL COMMENTS: "" DATE <br /> PHASE II GROUT INSPECTIO <br />�SPECTION BY 4 `. FH SE III FINAL INSPECTIO <br /> DATE +,: <br /> 14 26 Rev. 9/78 INSPECTION BY DATE c� �' <br />