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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _..�.._�.. <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 9 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (Eomplete .In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health' District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. ,1862 and the Rules and- Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT -STREET ADDRESS <br /> View j2r, Iracy CITY/TOWN <br /> Owner's Name r e Ca a � BId. cont. <br /> Phone 41 0 2448 <br /> .Address 2 Danville Calif. City <br /> .Contractor's Name Glenn Martell & Son Inc. License# 296448 Phone 41 . 432-428.2 <br /> IS CERTIFICATE OF WORKMANIS­. OMPENSATION INSURANCE ON FILE WITH-SJLHD? YES_-mss 0 2610 10 <br /> TYPE OF WORK (Check) : NEW WELLY# DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑- PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> SEWAGE -DISPOSAL M ELD CESSPOOL/SEEPAGEPIS— OTHER \ <br /> PROPERTY LINE - PRIVATE D MESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF-WELL.. CONSTRUCTION SPECIFICATIONS ' <br /> In ustr�— Cable Tool Dia. of We Excavation 1 001 <br /> '—Domestic/private ( Drilled Dia. of Well Casing 69 PVC UV <br /> Domestic/public Driven Gauge of Casing Class 160 <br /> Irrigation Gravel Pack Depth of Grout Sea 50' l <br /> Cathodic Protection i. XX Rotary Type of Groutcement . <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta�ed-By- <br /> PUMP INSTALLATION: Contractor Glenn Martell & Son Inc. <br /> Type of Pump u me rsr a H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work D _ • <br /> one <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth t <br /> Describe MateriaT and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <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 FORA GROUT INSPE TI Q PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: Prp, DATE: _ .1)- qq <br /> j DR P ON REVERSE SIDE <br />)HASE I FOR,DEPARTMEN ASE ONLY <br /> PPS LICATION ACCEPTED BY i .� //Z-� DATE 7 <br /> k DITIONAL COMMENTS: , <br /> PHASE 11 GROUT INSPECTION <br /> 14 .%► I -7q PHASE I FIN C ION �,y <br />'NSPECTiON BY .DATE _"w SY pAT��j14 26 Rev. 9/r f%7/77 40� A RO9vZ- 11�VSPECTION <br /> 779 <br />