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SAN JOAQUIN LOCAL-HEALTH DIS-fRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Av" ;° 'Sf6ckton, CA 95205 Permit-No. �. <br /> Telephone: (209) 466-6781 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued (,,,,-7- 7 <br /> This Permit Expires I Year From Date Issued <br /> f1 Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for permit to. construct- <br /> and/or install the work hereiin described. This application is made in compliance with San <br /> Joaquin County Ordinance NO".I 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. �-8-k4 <br /> EXACT STREET ADDRESS -j © 3 'A CITY/TOWN <br /> Owner's Name Phone <br /> Address City. <br /> ContractorsName ense# D Phone <br /> IS_ CERTIFICATE 'k <br /> F WORKM=S� COM tdSATIO'i Ii�SURA"dCE OT! LE WITH SJL.HD? YES NO <br /> TYPE OF WORK ,(.Check-).-- NEW--WEL-LW,- '- 'DEEPEN 0 RECONDITION ® DESTRUCTION[) �1 <br /> WELL CHLORINATION p WELL ABANDONMENT p OTHER 0 `W" <br /> , PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT j <br /> r <br /> DISTANCE'T0 NEAREST: SEPTIC TANK SEWER- LINES-1- ` P'IT-PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE f TYPE OF WELL Y CONSTRUCTION SPECIFICATIONS Q <br /> Industrial Cable Tool Dia. of Well Excavation ff <br /> k =Domestic/private Drilled Dia. of Well Casing <br /> ' Domestic/publicDriven - Gauge of Casing °Z <br /> Irrigation Gravel Pack Depth of. Grout Seal Q <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed, by: ef4tZeei-I <br /> PUMP INSTALLATION: Contractor <br /> S Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR:i ❑State Work Done <br /> DESTRUCTION-OF WELL: Well Diameter Appiwi'mate Depth <br /> Describe,'Material anid Procedure <br /> 4 <br /> raj hereby certify that I have ,prepared this application and.:that the work will be done in accordant <br /> iWith San Joaquin County Ordinances , State Laws, and-Rules and Regulations of the San Joaquin _l cal <br /> Health District. Home owner- or licensed agent' s signature'!s-tertifies the' following: <br /> I "I certify that in"the.-performanceof the-woi^k for which this permit is issued, I shall . <br /> not employ any persoK.'in such manner as to become subjec to;.Wbrkman' Compensation <br /> laws of California. <br /> I WILL CALL OR A GROUT INSP CTION PRIOR TO GROUTING NDA F.IN ` INSP N pp <br /> SIGNED_- TITLE: v. DATE: 6h��- <br /> ' DR W PL L N ON REVER E <br /> PHASE I FOR-.DEPARTMEN USE NLY <br /> APPLICATION ACCEPTED BY DATE '-/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECT-ION- PHASE III &IMAL INSPECTION <br /> INSPECTION BY DATE err :x <br /> 4 INSPECTION BY DATE �! <br /> EH 1426 Rpv- 12-77 1 1-7Q Om <br />