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JHN JUHQUl N -LUt;HL ,NtHL I h U!5 ! Kll:I <br /> FFICE_USE: 1601 E. Hazelton Ave. , S Wcktoll, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 r , <br /> ` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires -I •Ye-ar From Date Issued <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 application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and .Regu0/lations of .the San Joaquin-.Local Health <br /> District. I <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner' s Name J Phone zz <br /> Address w - . r City ' <br /> Contractor' s Name License#2 Phone_5Z -- /6 J <br /> IS CERTIFICATE OF WORK4 Ni�'S COMPENSA 0"1 INSURANCE OM FILE WITH SJLHD? YES P' 0 <br /> TYPE OF WORK (Check) : NEW WEL DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION Q ..WELL ABANDONMENT ❑ OTHER J <br /> PUMP INSTALLATION ❑ `;j PUMP REPAIR❑ PUMP REPLACEMENT El <br /> DISTANCE TO NERREST: SEPTIC TANK SEWER LINES- PIT 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 SPECIFIgATNS <br /> Industrial Cable Tool Dia. of Well Excavation <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 /> Disposal — Cher Other Information <br /> Geophysical' Surface Seal Instal ed :.^ <br />)UMPCo' <br /> U INSTALLATION: Contractor <br /> Type of Pump H.P. <br />'UMP REPLACEMENT: []State Work Done <br /> ,M � <br />'UMP REPAIR: ❑State Work Done r <br /> M <br />)ESTRUCTION OF ELL: 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 accord e <br /> lith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San oaquin Loc <br /> lealth District. Home owner or licensed agent's signature certifies the following: <br /> "J certify that in thejlperformance of the work far is permit is issued, I shall <br /> not employ any person"�in such manner as to beco subject t Work <br /> Comp hisatio <br /> laws of Calif nia. " � � <br /> WILL CALL F R GROUT INSPECTIO RIOR TO GROUTING A FIN) INS <br /> SIGNED �M TITLE: DATEAil <br /> M R W P OT PL N ON REVS IDE <br />'HASP I <br /> FOR DEP RTMENT U NLY ; <br /> � I� <br /> iPPLICATION ACCEPTED BY DATE <br /> @DITIONAL COMMENTS: <br /> PHASE II GROUT I SPECTION µ = =------WpHgSE III FINALINSPECTION <br /> NSPECTION BY _ 11. DATE INSPECT.ION BY <br /> 126 Rev. 12-77. 1/78 2M I <br />