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' SAN JOAQUIN LUCAL HLALIh <br /> FFICE USE: uta I Ittc:I : <br /> f 16Q.1 E. Hazelton Ave., Stockton CA 952Q5 Permit- Np - <br /> Tele hone: 466-6781 . <br /> Y p (209) <br /> APPLICATION FOR WELL CONSTRUCTION OR .PUMP'PERMIT Date:Issued <br /> ` This Permit Ex ares 1'Year From Date Issued ' <br /> Comp W n rip tate <br /> - �• <br /> Aoplication is hereby made to.- the•San Joaquin Local Health. District:1or 'a permit-to construct' - <br /> and/ar..instail~ h <br /> t e.::work herein described.- This application is made, in:compliance'witli <br /> oaquin:County Ordinance -No: 'lBfi2 -and the Rules 'and Regulations of the San:Joaquin=Local::'.Heal.th ` <br /> -1 strict. <br /> ' EXACT:STREETADDRESS <br /> Owner' CITY/TOWN ✓ 1 <br /> s Name - _:I <br /> v <br /> _Phone <br /> Address <br /> Y <br /> Contractor's- Name `` ' icense t <br /> L �_-'Phone :W-.2) =, rz <br /> rS CEIiTiF,ICATE.OF IJOPLi jid'S rnmr,EHSATIO`1 5URA"'ICE ON FILE WITH SJLNC?, YES <br /> L . <br /> -,YPE DF WO (Check): HEW-WELL❑ DEEPEN 0 RECONDITION Q DESTRUCTION <br /> -�� - WELL CHLORINATION D WELL ABANDONMENT p. OTHER p <br /> :•� " � N: <br /> PUMP', INSTALLATION ❑ PUMP REPAI R p r' PUMP,REPLACEMENT <br /> ,,DISTANCE TO NEAREST.' SEPTIC TANK "SEWER LINES PiT PRIVY <br /> 'SEWAGE DISP SteC-TIELD CESS L/SEEPAGE PTY, <br /> � ? PROPERTY. LINE'- PRIVATE <br /> WELL PUBLTCESTIC AEL � � <br /> INTENDED USE "�_� x` <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS _} <br /> ustr a - - .,- <br /> Ca a _Too Dia. of We Excavat on' . ting <br /> omestac/private Drilled . Dia. of Well': Casin <br /> ` , omestic/public Driven .: Gauge-of .Casing g. , -V4, <br /> Irrigation -Gravel'-Pack Depth of &rout;. ea ag <br /> 1 � athodic Pr Rotar <br /> k otection i <br /> y ,Type of:;Grout,.( Y... 4 t <br /> sposal . Other Other Informat ori ,yM� 1 <br /> r�f Geophysical - 'Surface Seal :Insta <br /> INSTALLATION _.ContractorlUv <br /> H <br /> Type 'of'Pump <br /> P P-}REPLACEMENT <br /> J state.work.Done R ? { � � <br /> Pi1MP REPAIR estate Work Done a <br /> DESTRUCTION OF WEtL`, WeIT:Diameter <br /> DeScri be MaterTa <br /> an Approximate':Depth' <br /> Procedure <br /> �Ir h Si0 .certify that I have prepared- this application and that the }Work wiTi.:be donein ecC"'C"t <br /> with;San,Joaquin. County:Ordinancess State. Laws, and Rules and Regulations of thd' San Joaquin l.o al <br /> ,Health District::' Homeowner or Ticensed'agen't's signature certifies:.the foiToriring <br /> ';I cerirify that in,ahe performance of-the work; for which <br /> ,this:perniit: is,issued, .I,..shalT+ <br /> not employ: any person in such manner as,'to become subject,.to Workman's `Com ensation }'fi <br /> s:.. <br /> of.;Call fornla." :. .:'._ :. p K ,C� <br /> �kI WILL CALL FOR ROUT INSPE ION PRTOR TO'GROUTING AND A F +AL INSPECTION. <br /> pSIGNED <br /> TITLE- <br /> D <br /> (DRAWON REV ---�- <br /> ' _ RTMENT USEi <br /> FQR, <br /> LY <br /> 10kASE' I r ti�' �`- cDEPA <br /> ' �' r a 4 <br /> A ON,-• CCEPTED '' .. ' <br /> ' Y <br /> _f ADDITIONAL-,COMMENTSi•;-'�'::-'.. ..:, DATE <br /> w, t .PHASE-4 U NSPECTION <br /> PHASEIII IHAL INSPECTION",. <br /> Hl�PEO7ION BY :DATE �` <br /> INSPECTION Sra <br /> Y DATE 7� <br /> { H;1426 .Rev. 1 <br /> r2M <br /> Tc <br /> .. .. F <br /> RB 9 <br />