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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Avco:-°° 9fo CA 95205 Permit No. `7q- V <br /> _f � - ckton, <br /> Telephone: (209) 466-6781 - 77 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued-,q-/4-77 <br /> (Co10lete_ In THpli tate) <br /> Application is hereby made to the San Joaquin Local Health District for a perm 'trto` construct <br /> and/or install the work herein described. This application is'-made in'coipliance with San <br /> Joaquin Cou ty. Ordin N 1862 d the Rules and Regu1 . •ons of the San 'Jo ui L cal Health <br /> District. a9 � . <br /> EXACT 'Sl` <br /> ET AD S CITY/TOWN_ f <br /> Owner c / U <br /> Owner's Name <br /> AddrACS <br /> Contractor's Na ' <br /> TqJ1_4111e Li -' <br /> cense#� �70�- Phone � ? ?�.X"' <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE"ON FILE WITH SJLHD? YES O -� <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN p RECONDITION [" DESTRUCTION 0 y <br /> WELL CHLORINATION Q WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR Cr PUMP REPLACEMENT`[ <br /> DISTANCE TO NEAREST: SEPTIC TANKv SEWER LINES 10 o PIT PRIVY-�- <br /> SEWAGE DISPO AL IELD i///d CESSP OL/SEEPAGE OTHER - <br /> - r PROPERTY LINE+ PRIVATE D MESTIC 'WELL P <br /> UBLIC D MESTIC WE <br /> 'INTENDED USE'' TYPE OF.WELL.._ CONSTRUCTION. SPECIFICATIONS <br /> Industria ....,,�.�.,� .,�; . <br /> Domestic/private Cable•Tool Dia. of Wel Excavat!on <br /> Domestic/public �-Dri]led Dia. of Well Ca.s�ing <br /> Driven Gauge of Casing o s p�, <br />��Irrigation �Grave'1 Pack Depth of Grout Se_a° S� <br /> Cathodic Protection _Rotary Type of .Grant_ <br />_ Disposals � <br /> eophysical Other Other Information <br /> Surface' Seal . Insta ed : <br /> PJJMP .INSTALLATION: Contractor ---- ^- -- � ; <br /> Type of Pump <br /> PJJMP REPLACEMENT: Q State Work. Done �. <br /> P^UMP REPAIR: ❑State Work (Done' <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materia ai� - Proce�ure Approximate' Depth <br />[ hereby certify that I have prepared thi's application and that the work will be 'done in accords el <br /> nl <br /> with San Joaquin County Ordinances, State. Laws, and Ru -and�Re,gul•at3ons of the••San Joaquin Local <br /> iealth 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 x <br /> laws of California. " , R <br /> WILL CALL FDR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />�GNED - <br /> TITLE: DATE <br /> -D W L N ON REVERSE SIDE — �--�•' <br /> RASE I . <br /> R DEP RT ENT USE ONLY � - f <br /> PP A�ION ACCEPTED BY <br /> DDITIONAL COMMENTS: - DATE_4z, <br /> q' x <br /> PHASE II GROUT INSPECTION <br /> i$PECTION BYDATE /�/J� PHASE III FINAL ' INSPECTION <br /> 1! 14 26 Rev. 9/78 INSPECTION BY DATE <br /> 0/7 0 00IA ! <br />