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SAN JOAQUINz,L0qAL F"�-ALTH DISTRICT <br /> FOR OFFICr'US.E:: 1601 E. Hazeltq� ;,Avec,.g Sto , ton, CA 95205 Permit No.26!., �, <br /> Tel epF oi�e.i, _�209 -6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Thi <br /> s ' rm `Cx ear 'from.Dte 'TSso"ed <br /> iromple a in Teioli <br /> Application is hereby made to the t� Ea � <br /> San Joaqu AfLocal; Health -Nstrzct:.i'Q,r •d, permit 6to,construct ' <br /> and/or � tl l ~thy cwerk <br /> herein des�cra taed Tia s appy�cati on; �s ~made :i n co�npl;a�,�+ce w�i th .San � <br /> Joaquin .Cozanty,c9r ,ihanre.,iNo�. 1862:xtU th fgm.les;:aanO,,Regulatloris,!©f, the fan; Joaqui,n, toca .,,Health <br /> District. <br /> EXACT'-S�`�fttA[ KESS - il/ . .,_ 4 .;. ' `CIATYtTOWN <br /> Owner's Name Phone 7�7.� <br /> Address... <br /> Contractor's Name &U, Mg/LJA& License# d Phone 7 3 'Z7 ` <br /> IS CERTIFICATE OF 140RIGlAN'S CO"zPENSATION INSURANCE ON FILE WITH SJLHD? � YES � .d0 <br /> TYPE-OF WOR!JCheck)-: NEW WELL Q DEEPEN Q RECONDITION fo DESTRUCTION d <br /> WELL CHLORINATION 0 WELL ABANDONME 0 OTHER <br /> PUMP INSTALLATION Q PUMP REPAIR O . PUMP REPLACEMENT [a <br /> DISTANCE TO NEAREST.:, SEPTIC TANK_ _ger SEWER LINES 9t9l PIS` PRIVY —� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT; OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL iiUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL, �,- CONSTRUCTION SPECIFICATIONS <br /> Industrial .�"`"�"�"""'Di ':"of'We11 Excav�,tion <br /> !Domestic/private Drilled. Dia. of Well Casing '/ i, <br /> Domestic/public Driven Gauge' of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �— <br /> , . +Cathodic„Protection Rotary Type of Grout &)(YST <br /> E�is`posaT''<_ Other Other. Information <br /> Iieophysi <br /> CAI ,- `4 Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> 7 <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: estate Work Done <br /> DESTRUCTION OF WELL%, Well Diameter Approximate. Depth _ _ - <br /> Describe Material an Proce ure <br /> I hereby certify thatI have prepared 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 to become subject to Workman's Compensation <br /> lams of California."/ <br /> I WILL CA FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. a <br /> SIGNED o TITLE: . DATE: /e--Z�Z 7S <br /> IF <br /> �UKAW PLOT UK ON REVERSE SIDE)FOR DEPARTMENT' USE ONLY <br /> PHASE I ' <br /> APPL'ICATI-DN—ACCEPTED' <br /> ADDITIONAL COMMENTS=PHASE 11 II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />