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SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> FFICE` USE: V/ 1601 E. Hazelton Ave: , Stocktbn, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT MDate Issued <br /> This Permit Expires I Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Lo.cal. ;Health District for- a permit to construct <br /> and/or install the work herein described: . This application is made incompliance with Sari . <br /> L'oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin. Local Health <br /> District. _ <br /> CITY/TOWN <br /> EXACT STREET ADDRESS , r <br /> Owner' s Name Phone m <br /> Address i'+ City . <br /> Contractor's Nave Li censef .11Y-_ Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"i TNS1108 r Ort- FILE WITH 'SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WEL 12 DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER F-3 w <br /> PUMP INSTALLATION U PUMP REPAIR❑ PUMP REPLACEMENT [I 9� <br /> ` W <br /> DISTANCE TO NEAREST: SEPTIC, TANK f SEWER LINES - PIT PRIVY �--- <br /> L�_� 1 <br /> SEWAGEIDISP�IELD 1 CESSPOOL/SEEPPGE PIT OTHER <br /> PROPERTY LT -f PRIVATE WELD -* PUBLTC DOMESTIC WELL 4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We11 Excavation �� <br /> Domestic/private Drilled Dia. of Well Casing + <br /> Domestic/public Driven —Gauge-of-C-.a-si-ng. ZZ _ I <br />� Irrigation : Gravel Pack Depth of Grout Seal f ` <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> w--Geophysical Surface Seal Installed by: r� <br /> PUMP I NSTALLATI ON: Contra�c o �'"I <br /> Type of P mp , <br />' PUMP REPLACEMENT: ❑State Work Done_ <br /> A <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ = Approximate Depth <br /> c Describe MAerial and Procedure <br />� I hereby certify that I have ,prepared this-a.ppli.cation 'and that`,theTwork 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&i n 'the performance,_of.. the''work for whi ch_thi s 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. " t <br /> I WILL CALL_.WR A GR UT P � PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED PM <br /> TITLE: DATE: z ze <br /> DR W PLOT PL N ON REVERS I E <br /> FOR DEPARTMENT USE ONLY <br />. PHASE I <br /> APPLICATION ACCEPTED BY DATE Q 7�. <br /> ADDITIONAL COMMENTS : 771,- <br /> PHASE,ki GROUT INSPECTION PHASE T FINA INSPECTION <br /> fTNSPECTION BY DATE Co INSPECTION BY . -- DATE <br /> :FW 1d.9i pow 19_7 �G� , A 1178 2M <br />