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.r I <br /> IF ' <br /> ' f <br /> SAN JOAQUIN LOCAL HEALTH UL51K1C1 <br /> EnFFICE USE: 1601 E. Hazeltun Ave. , Stockton, GA 95205 Permit No.7r—l�.Z� <br /> Telephone: (209) 466-6781; ' <br /> APPLICATION FOR WELL CONSTRUCTION OR :IPUMP PERMIT Date Issued12.;?o- <br /> This Permit Expires 1 Year From Daae Issued <br /> omp ete In Tr1pTTc-a-t-eJ {) i <br /> _. Application is hereby made to the San Joaquin Local Health District for a permit to construct. and/or install the work herein described. This application is made in compliance with San <br /> `.x Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. xt <br /> EXACT STREET ADDRESS ` Y C c. IM . CITY/TQUN <br /> Owner's Name 4f Phone' 3 5- J s ". <br /> Address_ City <br /> Contractor's Name <br /> Lij <br /> cense#Lq]�p� Phone X3.5-J,;��p�} J <br /> IS CERTIFICATE OF 1:ORK IA!VS CO' PENSATION' PISURANCE ON, FILE iftI fl SJLHD? YES <br /> TYPE OF WORK (Check): NEW WELLS] DEEPEN❑ RECONDITION 0 DESTRUCTION(:] � <br /> WELT. CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Iq PUMP REPAIR❑ '� PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIMES PIT PRIVY T <br /> SEWAGE DISPOSAL71ELD CESS /SEEPAGE PIT— OTHER <br /> PROPERTY LINE -. PRIVAT-E-W.ESTIC WELL PUBOC-U ESTIC WALT— <br /> INTENDED USE TYPE OF WELL 4CONSTRUCTION SPECIFICATIONS <br /> n ustr a a e ao Dia. of well Excavation <br /> domestic/privaterifled Dia, of Well Casing �� YF <br /> —"bomestic/public Driven Gauge of°;Casing LL C-1 ti <br /> Irrigation Gravel Pack Depth of !Grout 5eal <br /> Cathodic Protection Rotary Type of Grout - .4vT` <br /> x Disposal Other Other Informa on <br /> Geophysical Surface Seal Insta e , <br /> PUMP INSTALLATION: Contractor Ji. r <br /> Type of Pump , <br /> :r zR <br /> PUMP REPLACEMENT: ❑State Work Done E <br /> PUMP. REPAIR: <br /> E3State Work pone <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mater a an rote ure <br /> x � <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 ownir 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 Compersation <br /> laws of California." r <br /> I WILL CALL FOR A G OUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> ` SIGNED TITLE: DATE: p <br /> ON REV FOR -DEPARTRNT USE ONLY <br /> §r <br /> PHASE <br /> (I APPLIC (TION ACCEPTED BY <br /> ..�����;:.__ DAT ,.�--/�-�"'y-•' <br /> ADDITIONAL COMMENTS: ,1 '--- <br /> PHASE IMMOYINSPECTION ?'PHASf III FOAL INSPECTION Y <br /> INSPECTION BY DATE INSPECTION BY a. <br /> Est 1426 Rev. 12-77 !' is/78 2M ,f <br /> J. <br />