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FFICE Sr)' AQUIN LOCAL HEALTH DISTRICT , <br /> USE: 1601 E. f, _eltoAAve. 5 Permit No.TelephoAPPLIGATIODate Issued - -?N FSR WE0 OR1u;V4T 7 <br /> (Complete In Tri k )199 <br /> Plication is hereby made to the San Joaquin Lo c1 Vin <br /> for a permit to construct <br /> str'd/or install the work herein described. This a compliance with San <br /> ip' County Ordinance No. 1862 and Rules and Regulations of the San Joaquin Local Health <br /> strict. <br /> ACT .STREE DRESS <br /> ner` r CITY/TOWN�� z�� <br /> s Name JressPhone�p--,�Y%7j <br /> City <br /> itractor's Name .�.— <br /> v License#� 1 7�'hone <br /> CERTIFICATE OF WORKtiAN'S cnmPENSATIM INSURAINCE ON FILE WITH SJLHD? YES NO <br /> I OF WORK (Check) : NEW WELL 0 - DEEPEN C1 RECONDITION ❑ DESTRUCTION( <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER ( �- <br /> PUMP INSTALLATION Q PUMP REPAIR[q-- - PUMP REPLACEMENT [:) <br /> STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE I <br /> PROPERTY LINE A- PRIVATE—DOMESTIC PWELLSEEPAGEPUBLIC DOMESTICFIT RWEL <br /> INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Will Excavation ` <br /> Domestic/private Drilled Dia. of well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information— <br /> GeophysicalR. <br /> Surface Seal Installed by: <br /> INSTALLATION: Contractor ` <br /> Type of Pump H.P. <br />' REPLACEMENT: (State Work Done <br />�� <br /> REPAIR: CPSiate Work Do <br />`RUCTION OF WELL: � Well Diameter <br /> Describe Materianaan Pro re A proxim Depth <br />�reby certify that I have' prepared this appl.,ication and that the work will be done in accordant <br /> San Joaquin County Ordinances , State Laws ,' and Rules and Regulations of the San Joaquin Local <br /> th 'District. Home owner or -lice-nsed 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 a's .to become subject to Workman 's Compensation <br /> laws of California. " <br /> LL CALL FOR A GROUT INSPECTION PRIQR TO <br /> ED GROUTING AND A FINAL INSPECTION. <br /> TITLE:' DATE: <br /> DR W PL T PL N ON REVERSE . E — <br /> I F R EPARTM NT USE ONLY <br />[CATION ACCEPTED BY DATE 4/ /7,9TONAL COMMENTS: <br /> PHASE II GROUT INSPECTIQ <br /> CTION .BY DATE PHASE 111 "FINAL INSPECTIO <br />: ! <br /> INSPECTION BY DATE ' <br /> 26 Rev. 9178s 4 z 9M <br />