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SAN JOAQU IN,,LOCAL,-HbALTH UIS[R10-
<br /> L,,�S6ckton, CA t No.
<br /> -
<br /> FFICE USE: 1601 E. Hazel ton,,-,Ave-,. 95205 Permit Jl --
<br /> Telephone
<br /> Q
<br /> Tel epk6W6,.`.:,,. 1(209)` 466-678]'- ' Date Issued
<br /> APPLICATION FORWCCL CON'§TRUCTION OR PUMP PERMIT
<br /> This!'. '
<br /> 06r0it, Expirp' From.,Date-js'sue
<br /> Permit s I Year.
<br /> Cbm"'Ie' te ih,
<br /> p riplicate
<br /> -,,, . - � 1 ) 'I,
<br /> '... - i,.;,"' . .. 7 .. A - 11 . , I
<br /> Application is hereby made to the San Joaqui n Local,,:He.al,t,.h..,,,Q ,5:.tri,:qt .-for a. perm.0 t�.,. to construc.t.
<br /> and/or- -he:redfl, descri bed appl J,cAi-on, is Made,,j ncoippl-iance wj t.h,,5 a p
<br /> i on t I Health
<br /> lcaqu i n ap �he,Rul es'Lap
<br /> h San Local,
<br /> Distr4ct.
<br /> -'CITY,[TOWN 7
<br /> E S-TS'
<br /> EXACT
<br /> -4
<br /> Owner's Name_ Phone
<br /> AAddressy
<br /> Contractor' s Name S, Li cense#j4':Z5D_ Phone .
<br /> IS CERTIFICATE OF' WORKMAN'S COM-PENSATIO'111 INSURANCE ON FILE WITH SJLHD? YES . NO
<br /> TYPE OF WORK (Check) : NEW WELL 0' DEEPEN 0 RECONDITION ❑ DESTRUCTION❑
<br /> WELL CHLORINATION
<br /> 0 WELL ABANDONMENT 0 OTHER 0 u)
<br /> PUMP INSTALLATION g PUMP REPAIR 0 PUMP REPLACEMENT 0
<br /> 0C
<br /> DISTANCE TO NEAREST: SEPTIC -TANK SEWER LINES PIT PRIVY
<br /> SEWAGE DISPOSALFIELDCESSPOOL/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 Drilled Dia. of Well Casing
<br /> Domestic/public Driven Gauge of Casing se
<br /> Irrigation Gravel Pack Depth of Grout Seal
<br /> Cathodic Protection Rotary Type of Grout
<br /> Disposal Other other Informa'Flon
<br /> Geophysical ace SealInstalled by:
<br /> Vurf,
<br /> - PUMP INSTALLATION: Contractor. EA r Z-1
<br /> Type of Pump �.A��. 7�, \+3,- H.P.—
<br /> PUMP REPLACEMENT: [D Sta' te Work Done
<br /> IPUMP REPAIR: OState Work Done
<br /> ; DESTRUCTION OF WELL: . Well Diameter Approximate Depth
<br /> Describe Material and Procedure
<br /> iI hereby certify that I have prepared this application and 'that the work. will be done in accordant
<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 to become subject to Workman' s Compensation
<br /> laws of California.'!.
<br /> I `WILL CALL FOR _A'GRgJT I.N$PECTION PRIOR TO GROUTING AND A FINAL INSPECTION.
<br /> TITLE:SIGNED DATE:
<br /> E
<br /> I PLOT �PLAN ON REVEIRS�RUE
<br /> FOR DEPTRTMENT USE�ONLY
<br /> !PHASE I
<br /> D AT E
<br /> APPLICATION -ACCEPTED :BY A
<br /> ADDITIONAL COMMENTS,,!).:
<br /> PHASE I1 GROUT: INSPECTION PHASE' 'I I I FI-NAL
<br /> INSPECTION
<br /> INSPECTION BY DATE �: INSPECTION BY DATEZ
<br />
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