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SAN JOAQUIN !LOCAL,.HEALTH DISTRICT <br /> OFFICE USE: 1601 E_. Hazelton,Ave.b ., S;toc,kton, CA 95205 Permit No. 7�-5 a .2- <br /> Telephone: , (209) 4.6,6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued s-17-7, <br /> This. Permit"Ex ires,_1 -Year F.rom .Date .Issued. <br /> Complete In Triplicate ' <br /> Application is hereby made to the San Joaquin Local Health -Di-strict for .a. permit .to construct <br /> and/or, install thezwork herein described. This .application is made in compliance with San <br /> ,oaou i n County-=Ordinance;�No: 1862 and the Rules .and Regu.1 a.ti ons of, the San- Joaquin,Local Health <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name v 1Tvl i 6 �'� Phone �6 ��' <br /> Address ;..G .' <br /> Contractor' s Name � �—`� cul !' -� License,4•1--1593 Phon 46 6q4_1, ;I-fl <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES 740 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION C3 DESTRUCTION[ <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION CI PUMP REPAIR p PUMP REPLACEMENT p <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL -- <br /> A <br /> INTENDED USE TYPE 'OFLWEL'L'1, CONSTRUCTION SPECIFICATIONS <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 y <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: tate Work Done ` <br /> DESTRUCTION OF WELL: Well Diameter 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 GROUT INSPECTION PRIOR TOGROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: ft—_ _ _ DATE: .5)qJ � <br /> DR W PLOT PLAN ON REVERSSIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C DATE <br /> ADDITIONAL COMMENTS :PHASE II II GROUT INSPE � r PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE SPECTION BY DATE <br /> rki I enc n_.. 1 /'70 7M <br />