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SAN JOAQUIN-PLOC,-AL,°(-!H:E.,ALTH DISTRICT
<br /> FFICE USE: 1601 E. Hazelton Amj;, S,,t-ocLkton, CA 95205 Permit No.2f-11.5-
<br /> Telephone.:,,-, (209) Issued 7 Date I--
<br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT
<br /> 7u, "YJ
<br /> Thi s„Re rfl,t;,Expix#s �,!,,Year,zFroM,:Date,,;,Issued,
<br /> Application is hereby made to the San Joaqui-h:,-Lo-c6,1:.!,:He-a-Ith ,Di-.strict-.for -a-1permitsto-fcoh:struct
<br /> and/&'i,6-st a 11 the"Woift h rLl 1 n'I d e s c r tbe d Thts ,a p P-1 1,c at i`b h i s. -fna'de. i n s:com P I Ja nce With--San
<br />�Oaqlll 1862,j and thc.'Rul es ..!and,-Reg.u,,l at?tons-,eof..• the, San,,Joa.quin,rLoca1 Health
<br /> District.
<br /> 415
<br /> EXACT
<br /> ITY/TOIAN
<br /> E�TS
<br /> 4
<br /> 6-P
<br /> Owner' s Name N Phone_,�
<br /> Address
<br /> C tt.y.,�7 I
<br /> Contractor' s Name. R -,-,,-,. LicenseL725b Phone d S
<br /> IS CERTIFICATE OF.WORKMAN'S. COMPENSATI0!'1' I'NSURAmCE ON FILE WITH SJLHDI_ Y E S N0
<br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ORECONDITION M DESTRUCTION[D
<br /> WELL CHLORINATION WELL ABANDONMENT 0 OTHER 0
<br /> PUMP INSTALLATION PUMP REPAIR E7 PUMP REPLACEMENT [J (>C
<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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS
<br /> Industrial Cable Tool Dia. of Well Excavation
<br /> omestic/private I Drilled Dia. of Well Casing
<br /> Domestic/public Driven Gauge of Casing_ C-
<br /> Irrigation Gravel Pack Depth of Grout Seal
<br /> —Cathodic Protection Rotary Type of Grout
<br /> Disposal Other Other Information
<br />------Geophysical Surface Seal Installed by:
<br />'UMP INSTALLATION: Contractor
<br /> Type of Pump
<br /> H.P.
<br />'UMP REPLACEMENT: []State Work Done
<br />'UMP REPAIR: OState Work Done
<br />)ESTRUCTION OF WELL: Well Diameter Approximate Depth
<br /> Describ6 Material and Procedure
<br /> hereby certify that I have prepared this application and that the work will be done in accordance
<br /> iith San Joaquin County Ordinances , State Laws , and Rules and Regulation's of the San Joaquin Local
<br /> lealth 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 /> WILL CALL FOR A GROUT INSPECTION PRIOR TO' GROUTING AND A FINAL INSPECTION.
<br /> I G N E 0-25z TITLE: DATE;
<br /> (
<br /> 0 loor DRAW PLOT PL N REVERSE-OSIDE)
<br /> FOR DEPARTMENT USE ONLY
<br />'RASE 1
<br /> iPPLICATION ACCEPTED BY : DATE
<br /> ADDITIONAL COMMENTS:
<br /> PHASE. IfGROUT1NSPECTION PHASE III FINAL INSPECTION
<br /> NSPECTION BY
<br /> DATE 'INSPECTION BY
<br /> DATE E?
<br /> H 1a?F
<br /> Tw..,_1`7Q
<br />
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