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FFICE USE. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 Stockton E. Hazelton Ave; , `"— <br /> , CA 95205 Permit No.I? <br /> r Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued` <br /> i <br /> (Eomplete, In Tri p] i,cat e)' w <br /> s <br /> Application is hereby made to the San Joaquin Local."Health District <br /> and/or instal] the work �here'in described, t for' a permit ��to construct <br /> Joaquin County Ordinance No.f 1862 and the Rules and Reg' <br /> ofethe Sanin FJoaqu n Localwith aHealth <br /> District. <br /> R <br /> EXACT STREET ADDRESS' rg <br /> Owner's Name 7✓���1, �1 L �/ , CITY/TOWN JV <br /> Address ��l � % Phone <br /> . � <br /> Contractor's Name Z�1 7_t v �� Li censer .3� 1 <br /> Phoneme D. 4 <br /> I,S CERTIFICATE OF WORK11ANIS CQMPENSATIOPJ IPISURA�ICE ON FILE 4lITH SJtHD? <br /> TYPE 6F� � Check) '- <br /> _ YES r <br /> NEW° DEEPEN ❑ RECONDITION <br /> WELL CHLORINATION ® DESTRUCTION Cj <br /> OTHER 0 <br /> PUMP INSTALLATION Q MENT PUMPkREPAIR NI PUMP REPLACEMENT-Q , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' ' <br /> SEWAGE DISPOSAL FIELD, CESSPOOL-/SEEPAGE P1— OTHER <br /> PROPERTY- LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTICEI�'L <br /> a.. <br /> — INTENDED USETYPE - <br /> OF-WELL-.. CONSTRUCTION SPECIFICATIONS <br /> ----- Industria:l Cable Tool Dia, of We Excavation <br /> _Domestic/private° —Drilled Dia., of -Well Casing <br /> s Domestic/public Driven <br /> Irrigation - '"Gaug0of Casing �. <br />'Cathodic Protection } Gravel Pack ' Depth of- Grout Sea <br /> Disposal Rotary Type of Grout <br />;� Geophysical Other * Other In#ormation <br /> "Surface '.Seal Insta ed by:- <br /> PUMP <br /> -PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: <br /> M State Work Done <br /> PUMP REPAIR: L3. <br /> [Mate Work Don ' -� <br /> DESTRUCTION 'OF WELL: Well Diameter T ' <br /> - = - ApproximatesDepth <br /> Describe Material and Procedure <br /> r <br /> I hereby certify that I have prepared this application and that the work will be done in accordana <br /> Frith San Joaquin"County Ordinances, State.. Laws,, 'andRules and Regulations of. the .San, Joaquin Local <br /> lea lth. District. dome 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 t <br />' not employ any person in such manner as to .become subject to Workman's Compensation <br /> laws of California. " ; <br /> WILL CALL FOR A GROUT INSPECI`ION PRIOR TO GROUTING AND A .FINAL INSPECTION. <br /> IGNED <br /> TITLE: DATE: <br /> DR W PL T L N ON REVERS SIDE -- ` �-- <br /> HASE °I .. FO R EP RTMENT USE ONLY f <br /> PPLICATION ACCEPTED BY " 041 '� q <br /> DDITIONAL COMMENTS: ;� DATE <br /> PHASE II GROUT INSPECTION <br /> gSPECTION BY DATE PHAS I L INSPECTION <br /> 14 26 Rev. 9/78 INSPECTION 8Y DATE <br />