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SAN JOAQUIN LOi,, 1EALTH DISTRICT <br /> 'OFFICE USE: ' 1601 E. Hazelton AvL -,--,;tockton, CA 95205 [Date <br /> it N6. - -lye <br /> Telephone: (209) 466-6781 __ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Issued y_ <br /> This Permit Ex ires. I Year From Date Issued <br /> Comp ete. In,Triplidate <br /> Ao-plication is hereby made to the San-Joaquin Local>tiealth District for. a permit to construct, <br /> and/or install the work herein described. Thislapplication is made in compliance with San <br /> � JOaouin County Ordinance No.. 1862 and the Rules and' Regulations of the San Joaquin Local Health <br /> District. <br /> 3'6'rW W b, (.qcA 20 F20rh 14" 2-W <br /> EXACT STREET ADDRESS oh �i+e- P-I<d17 AArio S; f OF rH ��lp CITY/TOWN t_1NDE4 <br /> Owner's NameFLoRrs ,Tie Phone 97F7- 3b'IS" <br /> Address -2y?Z)LE 1 n G6st1 SdO'4rg Mar-;Vty <br /> L///1 �. <br /> Contractor's Name /Zc S s�uevisUJCE ' S� License j OS Phone r?7- 34/fZ-2 <br /> �. <br /> Is CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? - YES NO <br /> }TY-P_E OF_WOR,K-(Ghee) w,:NErI.WELL-L$- -DEEPEN-D—RECDND=ISIBN-[]e zDESTRULTION-© _ <br /> i WELL CHLORINATION ❑ WELL ABANDONMENT p OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> ` DISTANCE TO NEAREST: SEPTIC _TANK TANK-.20o ` SEWER LINES-aS D PIT PRIVY 4- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIS OTHER <br /> PROPERTY LINE -, PRIVATE DOFtESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ,Cable Tool Dia. of Well Excavation _ y-' <br /> X" `D6mestic/private Drilled Dia. of Well Casing /o " mow. <br /> Domestic/public Driven Gauge of Casing /p <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> -Disposal Other Other Information <br /> Geophysical Surface Seal <br /> PUMP INSTALLATION: Contractor ICOS13 ai¢yi <br /> Type of Pump15'r.9- <br /> PUMP <br /> r - r� P <br /> PUMP REPLACEMENT: []State Work Done a <br /> PUMP REPAIR: ❑State Work Done , . _ <br /> DESTRUCTION OF WELL: Well Diameter Approxima e Depth <br /> Describe_Mater_i.a._an. _P,roce ure. <br /> I hereby certify that I have prepared this,application and that the work will be done in accord <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Lol• <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 /> laws of California. " - L <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND'A FINAL INSPECTION. <br /> iIGNED 'i Q �� l i <br /> �`Q � � C�N TITLE: 0WNER, _ -DATE: <br /> MAW PLOT PLAN ON REVERSE SIDE � <br /> >HASE I FOR DEPARTMENT USE ONLY <br /> TION •ACCEPTED BY DATE <br /> kDDITI . <br /> 1DDITIONAL COMMENTS : <br /> PHASE'Ii GROUT INSPECTIO PHASE III FINAL INSPECTION / <br /> NSPECTION BY DATE S i INSPECTION BY DATE J <br />