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<br /> SAN JOAQUINLOQAL,�,:HE.Al DISTRICT
<br />- FOR O'FFICE USE: 1601 E. Hazel ton',"Av-e --i-I-Stoci-Talon, CA 95205 Permit No. 2jr-l-F24
<br /> Telephone:I e p hon'
<br /> (20)' 466=6781
<br /> V/ �
<br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued
<br /> This.,Permi FroM,,Qa ie ,Issue
<br /> Co
<br /> Tvpl ete. In 1i A
<br /> ,Tri pl i cate),..,
<br /> x 71
<br /> -.
<br /> Applicl,ation is hereby made to the San Joaquin1ocAl- Health %;Diistrict :for .a permit riot construct
<br /> and/o�,:';ffs.,tSlI','thef,wo,t�k herein 8escr-ibbd�; �;This,appl:icati�dn!.Tis �,,made-,:in.-compl-i-a.nc-e with l San
<br /> I ,;Local Health
<br />,oaquijn c,6un--tyier,,di;h6-ncen 1-4y, a1862-.and '.the. Rules of. the -San7Joaqujp._,
<br /> s t r il;c t.
<br /> EXACT !;STREET.' "ADDR'ESS '
<br /> CITY/TO N
<br /> Owner' s Name Phone
<br /> Addres!.s" Ci-,ty__S- b-Zk)�- -7-�
<br /> ,
<br /> J 4 la Z4--,d-
<br /> Contractor's Name Ai-rW J(dwz License f?zw* Phone. -
<br /> TS CERTIFICATE OF wouhPPCOMPENSATIO'll 1NSURA17..
<br /> 6M. FILE, WITH SJLHD? YES 9, 40
<br /> TYPE OF WORK (Check) : NEW WELL Q0 DEEPEN 0 RECONDITION [:] DESTRUCTION 0
<br /> WELL CHLORINATION C3 WELL A$ANDONMENT 0 OTHER 0
<br /> PUMP INSTALLATION [I PUMP REPAIR 0 PUMP REPLACEMENT [I-
<br /> DISTANCE TO NEAREST: SEPTIC TANK Q1j,, ,!;2)tSEWER LINES , PIT PRIVY cr-
<br /> SEWAGE DISPOS8�, FIELD + CESSPOOL/SEEP, PIT- t OTHER
<br /> .j C
<br /> PROPERTY LINEA41WRIVATE DOMESTIC WELLj_� UBLIDOMESTIC WELL
<br /> S
<br /> PE OF WELL CONSTRUCTION SPECIFICATION
<br /> INTENDED USE TY T
<br /> Industrial Cable Tool Dia. of Well Excavation J1
<br /> Domestic/private —Drilled Dia. of Well Casing
<br /> Driven Gauge of dasin '- A</)
<br /> Domestic/public Dri 4V Vd
<br /> of Grout Seal
<br /> Irrigation ravel Pack Depth of Grout
<br /> Cathodic Protection Rotary Type
<br /> Disposal Ii. _F
<br /> Oth&-— Othe - Information
<br /> Ei Geophysical Surface Seal Installed h
<br /> PUMP INSTALLATION: Contractor
<br /> Type, of- Pump H.P.
<br />' PUMP REPLACEMENT: []State WorR7 Done
<br /> PUMP REPAIR: OState Work Done
<br /> DESTRUCTION OF WELL: Well Diameter k Approximate Depth
<br /> Describe Material ana Protedyre
<br /> II hereby certify that I have prepared this application and that the work will be done in accordant(
<br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local
<br /> agent's signature certifies the following:
<br />� Health District. Home owner or licensed
<br /> 1; certify that in the performance of the work for which this permit is issued, I shall
<br /> not employ any person in such manner a5 to become subject to Workman's Compensation
<br /> laws: of California. '
<br /> ; I WILL CALL FOR A G,ROUT/jIll V,,1E.V1ON. PRIOR TO,GRQUTING.AND A FINAL INSPECTION.,
<br /> S
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<br /> S I GNE;b TITLE: ZZ. DATE:-/S.
<br /> (DR PLOT PLN ON REVERS SID
<br /> FOR RTMENT,, USE ONLY
<br /> PHASE' I �7
<br /> DATE
<br /> APPLICATION ACCEPTED BY AdgZ - --- — _ 7ZO
<br /> I L( &.,�I rZ
<br /> ADDITJONAL COMMENTS:
<br /> PHA%E II: GROUT INSPECTION PHASE III FINAL INSPECTION
<br /> ,INSPECTION BY DATE 16)%9�� INSPECTION?�T
<br /> B
<br /> r'Li 1 A,r)9Z D-' 19_'77-`- "' - '1178 2N,
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