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SAN JOAOUIN�U� �C <br /> J�AM�HL|H ���TRl[T <br /> - - | <br /> FOR OFFI-CE USE: 1601 E. Hazel CA 95205 . <br /> | <br /> Tel h0A��' '(2Oq). - ' 8I <br /> ' | ` �-^ `-�-' ' ' ' <br /> ^ PERMITDate IssuedAPPLICATION FOR WE,LL CONSTRUCTION OR PUMP <br /> (-Compl et <br /> Application is hereby made to.._1 the San Joaquin a c6 : <br /> t CITY/TOWN <br /> EXACT STREET �t.DR <br /> Owner' s Name c4t C Phone <br /> Contractor' s Na-me- License# Phone . <br /> 'OMPENSATION INSURANCE ON FILEWITH SJLHD? YES NO <br /> TS CERTTFICATE OF WORKMAN'S C <br /> ITYPE OF WORK (Check) �:- NEWWELL 0 DEEPEN 0 RECONDITION DESTRUCTION <br /> 0 T H E R Bta,�/�14 <br /> WELL CHLORINATION WELL ABANDONMENT 0 <br /> PUMP REPAIR 0 PUMP REPLACEMENT <br /> PUMP INSTALLATION <br /> iDISTANCE TO NEAREST: SEPTIC- TANK - SEWER LINES PIT PRIVY <br /> SEWAGE- DISPOSAL FIELD . CCSSPOOL/SEEPAGE OTHER IN, <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT IONS <br /> ndustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled . Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal --------- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal -Other Other Information 7 <br /> Surface Seal Instil ed by: <br /> eophysical <br /> ' PUMP INSTALLATION- Contractor <br /> Type 0'f Pump H.P. <br /> [ PUMP REPLACEMENT: State Work Done <br /> k. PUMP REPAIR: PState Work Done <br /> .1 imate Depth <br /> ,DESTRUCTION OF WELL: Well Diameter-� Approx <br /> Describe Material and Procedure <br /> ' <br /> � I hereby certify. that I have prepared this application and that the work will be done in accordanc <br /> k with San Joaquin County Ordi6ances , State Laws , and Rules and Regulation's of the San Joaquin Local. <br /> iHealth District. Home owner, or licensed agent' s signature certif'ies. the following: <br /> : "I certify that in t4e performance of the work fot which this permit is issued, I shall <br /> i not employ any person in1such manner as" t6become subjdct to Workman!'s Compensation <br /> laws of California."' <br /> I WILL CALL FOR A :GROUT ,INSPECTIO PRIOR TO GROUTING AND AFINAL INSPECTION. <br /> (DRAW P-LOT-L PLAN ON REVERSE SIDE) <br /> FOR DEWTMENT USE ONLY <br /> DA <br /> 'ED By <br /> 'ADDITIONAL COMMENTS : INSPECTIQN <br /> 'INSPECTION BY <br /> :INSPECTION BY DATE DATE <br /> 78 ­2M <br />