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AUIN <br /> HEALTH <br />• FFICE USE: 1601 EANHaz0e4ton Ave <br /> StocktoDISGAICT <br /> �t <br /> Telephone: (209) 466-6781 95205 Permit No. — <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a Permit; to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. a �. f <br /> 2--s-3 - 330 -3S <br /> EXACT STREET ADDRESS / CITY/TOWN s� <br /> Owner's Name ly�� - p��J� �„ / •-,C Phone �2c� <br /> Address Cit <br /> r y <br /> Contractor's Name ems-' Licensed .2 ,2- Phone Z ) Z__:.) <br /> IS CERTIFICATE OF WORKMAN'S C0,11PENSATION INSURA"PCE ON FILE WITH SJLHD? YES 0 4 <br /> TYPE OF WORK (Check) : NEW WELLLZ DEEPEN ❑ RECONDITION ❑ DESTRUCTION[ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION M PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES -- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE P�— ' OTHER <br /> PROPERTY LINE -PRIVATE DOMESTIC WELL . PUBLIC D MESTIC WELL - <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial bTe Tool Dia. of W_eT7_Exc <br /> Domestic/private Dril e Di asing <br /> _Domestic/public . Driven of Casing f <br /> Irrigation Pack Depth o ea <br /> __ Cathodic Protectio Rot <br /> Disposal — Rotary y Type of Grout e- <br /> ti <br /> al Other Other Informaon <br /> Surface Seal Insta e : 0.4✓ >-L -ev <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done "- <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materia an —Procedure Approximate Depth <br /> I 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 CRLL FOR A GR <br /> iIGNED OUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE: DATE: <br /> QR W PLT L N ON REVERSE SIQE <br />'RASE I FOR DCPA TM Npr <br /> USE ONLY <br /> IPPLICATION ACCEPTEDBY <br /> 0DITIONAL COMMENTS: DATE d5�3-?x <br /> PHASE II GROUT INSPECTION <br /> NSPECTION BY DATE PHASE IIi FINAL INSPECTION <br /> H 14 26 Rev. 9/78 INSPECTION <br /> 9/718 M <br />