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SAN JOAQUINT,,,LtQQA4,,,,H,�,�ALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton-An <br /> ve ­ S1oc,kton, CA 95205 Permit No. <br />.-EQR 0 <br /> (2 4:66-6781 <br /> Tel ephone�)�-. <br /> V-- f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -7 <br /> u <br /> -Per rbs F,1,.Ye4:r, Fro _Q.oteIss6ed'. <br /> This, mi.t;' J Expi, M . <br /> a Complete In Tri:p1icat <br /> e) <br /> _ , _ J4 <br /> Application is hereby made to the San Joaquin'`L-.uca:,lT,.;SHe;a(,lthe,,Di,stri-ct;-.-,f,�or, ..a;�,perm,.itto-.cohstruc.t, , <br /> he 'described -This a:pp1i-cat-irohiis: -made? in; compli anc8 with;,San.:j -,.' <br /> they ul es,�.a.nrd 'Requl ation s.,of, the iSanx Joaqu i r:�Local Health <br /> s t r c t. <br /> 'EXACT �Tkftl_ A tS� CITY/TO N <br /> Owner' s Name Phonk2a!�,__­ <br /> ty <br /> Contractor' s Name . Li cense# Phone .< <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATI01111 IINSURAINCE ON FILE.WITH SJLHD? -YES NO <br /> TYPE OF WORK (Check) : NEW WELLJM__ DEEPEN []. RECONDITION (D DESTRUCTION[3 Z <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER <br /> PUMP INSTALLATION 0 PUMP REPAIR 0 PUMP REPLACEMENT [I <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 TOE OF WELL CON.STRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _Domestic/private Drilled Dia. of Well Casing 7;1_/ 4 <br /> Domestic/public Driven v . Gauge of Casing S <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type Of Grout Q- V <br /> Disposal Other Other Information <br /> Geophysical q Surface Seal Installed by:__ <br /> PUMP INSTALLATION: Contractor Q_ <br /> Type oflPump— H.P. <br /> PUMP, REPLACEMENT: F]S°tate Work Done <br /> PUMP REPAIR: OState Work Done <br /> DESTRUCTION OF WELL: Well Diameter.. Approximate Depth <br /> Describe Material and Fr—ocedure <br /> I hereby certify that I have pirepared 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' tolbecome subject 'to Workman's Compensation <br /> laws of California." <br /> I WILL CALL FOR A OUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE:-;gate DATE: <br /> (DRAW PLOT PLAN ON RE RIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II: GROUT INSPECTION . . ; PHASE III. FINAL INSPECTION <br /> INSPECTION BY : DATE INSPECTION BY <br /> DATES AL_lj' <br />