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SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Age. ;. tockton, CA 95205 Permit No. 21�17 7 ' t <br /> 'j Telephone:'; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ` <br /> ires .I,Year ,From Date Issued <br /> This .Fermit=Ex. <br /> l Complete In Triplicate <br /> • ,111' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein'!Jdescribed. Thi's application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and ,Regulations of the San Joaquin Local Health � <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name ICA 'Il 11iiPhone <br /> gill " <br /> Address Z. Pa . a �• City ."7r <br /> Contractor' s Name License# Phone t 6 <br /> IS. CERTIFICATE OF WORKMAN'S CO, PENSATION INSURANCE ON FILE WITH SJLHD? YES NO � <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN L7 RECONDITION C3 DESTRUCTION( <br /> WELL CHLORINATION [3 WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION J�D PUMP REPAIR d PUMP REPLACEMENT C <br /> DISTANCE TO NEAREST: SEPTIC `ANK__& ! SEWER LINES PIT PRIVY OTHER � <br /> SEWAGE DISPOSAL FIELD ;U CESSPOOL/SEEPAGE PIT- ., i <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL "PUBLIC DOMESTIC WELL <br /> INTENDED USE p TYPE OF WELLCONSTRUCTION SPECIFICATIONS <br /> Industrial ;I Cab.l e 700 Dia. of Well ExcavationDomestic/private 7 D^i 11 ed } ;:Di4a., o f,.,Wd.,l luC�-NCng <br /> �—Dome stic/publ-i-c" J Driven Gauge of Casing e' <br /> Irrigation dl Gravel Pack Depth of Grout Sea 011- . <br /> Cathodic Protection II Rotary Type of Grout <br /> Disposal ,�li 0`ther Other Information <br /> Geophysical ! Surface Seal Installed by: <br /> Jil1,r <br /> PUMP INSTALLATION: Contrad or <br /> Type of Pump , S� —4 H.P. <br /> /! <br /> ;1 <br /> PUMP REPLACEMENT: F7 State Work, Done 4i' <br /> PUMP REPAIR: QState Work. Done <br />;,,DESTRUCTION .0> WELL: Well D7lameter" t�" � ° �' - Approximate Depth I <br /> Descrl b'e Materi a an Procedure r_ 4 <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 dr 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 Iiu ch manner as to become subject to Workman's Compensation <br /> C laws of California. " ' <br /> i' I WILL CALL FORA ROUT'INSP£CT N PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> F SIGNED IC TITLE: �' � " DATE: 7-2 J"7,�? <br /> DR W PLOT PLN ON REVERSE SIDE <br />' FOR DEPARTM NT USE ONLY <br /> PHASE I DATE� �7� <br /> APPLICATION ACCEPTED 8Y <br /> ADDITIONAL COMMENTS: IE' <br /> SE II ROUT INSPECTION PHASE III FINAL INSPECTION 1. 9 <br /> INSPECTION 8 f DATE f INSPECTION BY DATE <br /> y 1/7-8 2M <br />