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<br /> SAN.JOAQUIN:LOCA L-HEALTHj:01STRICT
<br /> FF E-USE
<br /> 'fi .1601 %E =Naxe1 ton.Ave., Stockthn, CA'. 95205 , Perntit=No::
<br /> .x. - Telephone (209)',.,466-6781
<br /> Date,.Issued ` _•R. • i.
<br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITS
<br /> � �{.• ,-,?9`- .�- a �.:_ x- •>s
<br /> 'This',Permit'-Expares 1'Year:from'Da to Issued A r• �d.;s°
<br /> 777
<br /> 41 Hn.f.:ow
<br /> e : n Tri plcate -
<br /> l � a r h ,
<br /> - tea
<br /> Applicatan i5 hereby made to the `San:;Joaquln°.Local Health:District'tfor` a; pernti't�yEb.4construct.
<br /> M. ...- -
<br /> �� and/ori?nstalTR;%he work herein 'desCr,ibed THis :application is: madey-in cvmpi.iance.':with;,San �_
<br /> _ ;:oaquirnCounty 1,rdinance ?do 1862_and the Rules and Regulations of the;San.JoaquinrLacal,iyyy3',l`�eal:th
<br /> „ rli5 tri ct- -A' v[fit+✓' 1.1 - - -,..rr...di a "C'f+•r�+'Y : i �
<br /> EXAC- 'STREET,,ADDRES5
<br /> ners ae Phon�e.. ,ff
<br /> ess f• s
<br /> r� Addr � � �� C
<br /> Contractor's Name Licensee Phone
<br /> .� ."- r .. - '
<br /> IS-"CERTIFTCATE;=OFRK!R
<br /> =WOANI,S,COM PEN SAT 10.11 INSURANC om, riLE' WITH.SJLHD? ..YES •
<br /> TYPE OF WORK {Check) NEW:.WELL �. - DEEPEN❑ RECONDITION Q DESTRUCTIONQ
<br /> WELL::CHL NATION p -.WELL ABANDONMENT❑ ,;OTHER❑
<br /> PUMP"INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q 4
<br /> :DISTANCE TO NEAREST SEPTiC TANK SEWER EINES- �s,PIT::PRIVY�=
<br /> ... .., r SEWAGE*<DISPff5 FIELDI '' CESSP40L/SEEP GE:.PI f ; ;OTHER:== �
<br /> :: - ' PROPERTY I IN �f PRIVA`TE DOME
<br /> STIC`WELL PUBLIC DOMESTIG:WELL
<br /> INTENDED.SSE r TYPE`OF WELL C0IVSTRUCTIDN`SPECIFICATIONS � `'
<br /> z In ustr,ial Cab a Tool; Dia. of We Excavation
<br /> .'_7-17Y70omestic/privatel - '- Drilled Dia. of-,Wel3 Casing
<br /> , - Y
<br /> £ :s
<br /> Domes tic/public'# Driven Gauge of:Casing - �csra
<br /> Irrigation Gravel Pack Depth of Grout, a
<br /> ,.r
<br /> Cathodic Protection Rotary Type of Grout,:':""' cs.1.�:.,L _ti_r • 7.r * "
<br /> ' Disposal Other Other Information ---:.,�Y;.f-.• � ;
<br /> xGeophysical Surface Seal Ins tal led
<br /> PUMP;fINSTALLATION Contracto —/S� �fy+fi
<br /> TYpe of A mp
<br /> r Done-
<br /> ?,'PUMP-:REPLACEMENT:. ❑State Work _
<br /> PUMP -'REPAIR:. (]State Work ©ons r_• �.�rT'Gi* "� `� "
<br /> F
<br /> DESTRUCTION OF WELL Well Diameter Approximate Depth
<br /> Describe Material and Procedure ��r : _ "" `•� ;�,w
<br /> t I hereby certify'that I have prepared this application and that t:he work will be done- in accordari e i
<br /> . ; with: San Joaquin County Ordinances, State Lawsand Rules and Regulations of the San Joaquin Local 7
<br /> . Health. Distri ct:- •Home owner or licensed agent's si nature certifies-the'folIowin ,
<br /> f "'"I certify that -in the performance of te work for which .this permit is issued, I 'shallfil.
<br /> not:employ any person in such -manner as to become subject to Workman's Compensation ` � f F
<br /> t y ' laws of, California.
<br /> 'I WILL CALL R A GR LST SP TT N PRIOR TO GROUTING AND A FINAL INSPECTION
<br /> TITLE:
<br /> �
<br /> SIGNED /�Co6s — DATE:
<br /> DR PLOT—PLAN ON REVERSEL
<br /> FOR DEP R MENT USE ONLY
<br /> PHASE I =
<br /> PPL 1C TION ACCEPTED 8Y DATF
<br /> ADDITIONAL CCh1�3EN'S:
<br /> j PHASE,;•I GROUT INSPECTION 1 , r PHASE II, FINA INSPECTION ;s
<br /> INSPECTION BY/��ft..,' DATE INSPECTI011 BY/Ir/ s. .- DATE
<br /> All
<br /> EH 126 ?.ev. 12 7.T ri 4'
<br /> 1.
<br /> _ -
<br /> HB-7 �
<br />
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