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'S* / SAN JUA[�UiN. LUGAL HERLIH U15IKiLI Permit No. <br /> �/ 1601 E. Hazelton Ave. , Stockton, CA 95205 Y., <br /> FOR. OFFICE. USE: Telephone: (209) 466-6781 <br /> Date Issued 3U- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> ThisPermit Ex ires 1 Year 'From bate Issued' <br /> Complete In Triplicate <br /> is hereby made to the San Joaquin Local. Health .District made inrcompliancetwith. Sanuct <br /> Application y application is <br /> and/or install the work herein .described.. This <br /> ;n- Count Ordinance No.. 1862 and the .Rules and Regulations. of the San .Joaquin Local Health <br /> f <br /> ,.oaqu Y " <br /> District. '7 Cr�ia �l CITY/TOWN__ <br /> EXACT"STREET ADDRESS U �- fG Phon <br /> Owner' s Name !l C <br /> City P9 r" <br /> Address �? 0 <br /> Li cense6V©/43 Phone L 6 <br /> Contractor' s Name <br /> TS CERTTFTk ATE OF WORKMAN'S C04,SPENSATIO'N I"SURA^!CE ON FILE Ir1iTFl SJLHD? YES NO <br /> ` DEEPEN ElRECONDITION DESTRUCTIONJ� <br /> TYPE-OF WORK (Check) : NEW WELL K. OTHER 0 <br /> WELL-- WELL CHLORINATION3 PUMP REPADIR❑ NT a MP REPLACEMENT Q <br /> PUMP INSTALLATION <br /> DISTANCEVTO�NEAREST: SEPTIC TANK��. SEWER LINES <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPUOL/SEEPAGEP�g�DOMEOTIERWE L ---- <br /> ' �- PROPERTY' LINE PRIVATE DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> ' CONSTRUCTION SPtCIFICATIONS <br /> able Tool Dia. of Well Excavation <br /> Industrial �C Dia. of Well Casing <br /> omestic/private Drilled <br /> Gau <br /> ven ge of Casing 2- <br /> t Domestic/publicGravel Pack Depth of Grout Sea <br /> I Irrigation ..Type of Grout <br /> Cathodic Protection Rotary <br /> Other. Other Informat on <br /> Disposal Surface Seal Instal ed b <br /> Geophysical <br /> PUMP, INSTALLATION: Contractor <br /> Type-of Pump <br /> E3 State Work Done <br /> G PUMP: REPLACEMENT: Q _ <br /> PUMP .REPAIR: clstate Work Done <br /> DESTRUCTION <br /> F WELL: Well .Diameter Approximate Depth�� <br /> -,-Describe Material and Procedure . <br /> I hereby certify that I have prepared this application and that the work will be done in accordan <br /> San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <br /> with <br /> Health District. --Home-owner <br /> rformances d thenworksforawhichcthisfpermiteisoissued, I shall <br /> "I certify that in the performance .d& <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 PRI TITLE:AND A FINAL INSPECTION. DATE. D <br /> . <br /> SIGNE " TITLE: <br /> f DR W PL L N ON REVER E SIDE <br /> F R DEPA TMENT dSE ONLY <br /> PHASE I 41 <br /> DATE L 3d 7d� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE .III. FINAL INSPECTION_ pNA5E_II GROIN.IIVSPECTI.ON. ..,� �,..; ..�.- . - � x - . .-- DATE/Z,/q-751 <br /> f INSPECTION BY DATE ;INSPECTION B <br /> r 1/78 21 <br />