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7 SAN JUAQUIN LUI.AL MtAL I n uj�)J KI '95205 P <br /> ermitt No. - <br /> Stockton, CA <br /> FTICE USE: 1601 E. Hazelton <br /> 466-6781 Issued <br /> Tel ep <br /> APPLIC <br /> ATION FOR WELL, CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ices 1 Year From Date Issued a <br /> Complete In Triplicate ermit to construct <br /> tion is made in compliance With- SaHealth <br /> hereby made to the San Joaquin LocalHealthDistrict far a p oa uin _ <br /> Application is Y <br /> and/or install the work herein described. This PP <br /> 'Hance No- .1862 and the Rules and Regulations of the San qal . r <br /> ,.oaquin County Or�� CITY/TOW <br /> Di.strict. a <br /> EXACT�� STREET ADDRESS Phone G° <br /> Owner's Name S City S <br /> � : a c Phone <br /> Address S License# <br /> Contractor' s Name <br /> 4,PENSATI4"! i'15URA'!C£ Otd FILE WITI1 SJLHD? . YES "d <br /> 4 I5 CERTIFICATE OF 1JOP.K IAId S CO RECONDITION ® DESTRUCTIO& G <br /> DEEPEN ❑ OTHER n <br /> 11 ?YPE OF WORK (Check) WELLNEW CHLORINATIONINATION CJ. WELL ABANDONMENT 0 Mp REPLACEMENT L� L <br /> PUMP INSTALLATIONS PUMP REPAIR d <br /> SEWER LINES PIT PRIVY_ 'OTHER <br /> ! DISTANCE TO NEAREST: SEPTIC TANK S : � CE5 PS OOL/SEEPAGE PIT s <br /> ! SEWAGE DISP SAL FIELD, non�PUBLI D ESTIC WELL <br /> i PROPERTY LINE - PRIVATE DE OMESTIC WELL*� RUCTION SPECIFICATIONS <br /> TYPE OF WELL CONS <br /> Dia. of Well Excavation <br /> r INTENDED USE Cable Tool <br /> Industrial.�� Dia. of Well Casing, <br /> -----� ri nate. _ Dri 1 l.�ed. .- �:, r <br /> Domes c/.p � ._.��_�Gauge--of<-a-si-n r <br /> - pub i c _ �__Dri__en_ <br /> -zDotnest`ic/p' Gravel Pack D6pthof- Grout,. <br /> of- Grout, Seal S. �: . .. <br /> Irrigation Rotary . Type of Grout _N :�,: <br /> Cathodic� Protection Other�� Other Information."Disposal Surface Seal Installed b <br /> Geophysical ti <br /> PUMP INSTALLATION: Contractor H.P. ? <br /> Type of Pump <br /> PUMP REPLACEMENT: C]State Work Done <br /> " <br /> PUMP REPAIR: QState Work Done <br /> f Approximate Depth <br /> DESTRUCTION OF WELL Well Diameter <br /> Materia _ and Procedu <br /> Describere . <br /> = . <br /> 'Thereby certify that I_ have prepar <br /> with ed this app <br /> lication and that the work will be done. in accord <br /> ! Joaquin County'Ordinances , State Laws , and Rules and Regulations of the San Joaquin Lc <br /> San q <br /> Health District. dome owner or l i ceased ��enwo,rk' forawhi ch, sfper_mit_i s�i ssuedg- I steal I <br /> "I certify that in the performance o ' <br /> tion <br /> 'not employ any person in such manner as to become subject to;Workman' s"Compensa <br /> " laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTI <br /> GRODATE. ` <br /> TITLE: <br /> SIGNED DR W PL T PL N ON REV S SIDE <br /> FOR DEPARTME T USE ONLY <br /> PHASE I DATE <br /> i APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTIO <br /> PHASE II GROUT INSPECTION INSPECTION 8'( cn DATE <br /> I INSPECTION BY ' DATE <br /> L .. 1178 <br />