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SAN JOA UIN LO[' <br /> `OFFICE USE: l EALTH OISTRhCT <br /> 1-�---__ 1601 E. Hazelton Ave�';`�tockton, CA 95205 EDate <br /> t No. �1 <br /> t Telephone: (209) 466-6781 <br /> +, APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Issued_±__212L-jE' <br /> This Permit Expires I Year From Date Issued <br /> - (Complete. In Triplicate <br /> AO-plication is hereby made to the San-Joaquin Local,,Health District for a permit to construct, <br /> rand/or install the work herein described. Th.isjapplication is made in compliance with San <br /> Iuoanuin County Ordinance No. 1862 and the Rules and' Rbgulations of the San Joaquin Local Health �. <br /> Distr?ct. <br /> EXACT STREET ADDRESS 1yq 1n,v- scwTW W L. Irgcg 20 r2anl awl 2.10 <br /> P an !�+ P,i�rtT 1aAN� s iF r Rom© CITY/TOWN �_ll DEl,) <br /> Owner's Name ,zrNvtz. , o z S!/R2ocj lLoe s ,T� Phone <br /> Address �1�'r1Sa�' 4�rd Mar�•o <br /> City .L <br /> Contractor's Name /Zc�S,S �vevigJ/CE S,z License j _ Phone 31-Itz:2 <br /> 7 ISCERTIFICATE OF WOR"IAN'S CTMPENSATIO1111 INSURA'!CE Orl FILE WITH SJLHD? - YES NO <br /> TY--RE_OF.-WORK--(.Chen-k).z...rNE'rt►WE-L-L-M--DE-E-P-EN-C RE64N.D�l-T4,0 �= i <br /> WELL CHLORINATION N-C� DES�RJ.CILON_©=„� <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ NT PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC -TANK:20o ' SEWER LINES-:;L S d PIT PRIVY N <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �lY <br /> INTENDED USE TYPE OF WELL <br /> - In ustrial CONSTRUCTION SPECIFICATIONS <br /> X"' <br /> �' Cable Tool Dia, of Well Excavation i y--' <br /> Domestic/private Drilled Dia. of Well Casing <br /> /pDomestic/public Driven Gauge of Casing <br /> 666 <br /> Grave <br /> � <br /> Pack Depth of Grout SeaI <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ��a— <br /> Other Other Informatlon _ <br /> Geophysical Surface Seal Installed b : f ;v <br /> -PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> UMP REPLACEMENT: P <br /> [IState Work Done <br /> PUMP REPAIR: ❑State Work Done— <br /> _4(2 <br /> ESTRUCTION OF WELL: Well Diameter <br /> Descri be_Materi.a__an. .Rroce ure- - APproxima e Depth <br /> hereby certify that I have prepared this-application and that the work will be done in accord; <br /> ,rith 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. " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING ANDA FINAL INSPECTION. <br /> _iGNED-/ o TITLE: ., ()WrJC_R, , -DATE: <br /> �KAW PLOT PLAN ON REVERSE SIDE <br /> 1 <br /> '- "FOR <br /> IAS E I DEPARTMENT USE ONLY <br /> �, <br /> (rPLICTION,ACCEPTED BYDATE <br /> kDDITIONAL COMMENTS : _ZdZ4 <br /> PHAS P I-I GROUT INSPECTIO <br /> -.SPECTION BY PHASE III FINAL INSPECTION <br /> ' _ DATE STt INSPECTION BY DATE <br /> a ,�.y a <br />