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SAN JOAQUIN-10CALHEALTH DISTRICT 'e ;�s
<br /> FOR E USE: V 1601 E. Hazel tnn Rtockton, CA 95205 Permit.'No. 7l
<br /> Telephone: (209) 466-6181
<br /> �Er AF:1ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date.Issued
<br /> .
<br /> This.
<br /> Permit Ex ires. 2-Year, rum Date-, Issued
<br /> x ,Iori ete n r tate
<br /> Ap'plicati'on is' hereby made to the San ,ioaquin LocaluHealth District' for,a�perniit tofconstruc�
<br /> and/or install: t�ie'work herein described. This.appl-ication,is made"'in. complianCe��riFth Snit
<br /> J1.
<br /> oaqui n .011. Ordi na'nce,Novi- 18552 and the Rules and,Regul at l ons•,of4 the;xSanr Joiqufnr)Lo al He 1,t
<br /> Mistri ct:
<br /> EXACT STREET -ADDRESS CITY/TO {
<br /> O�ner's Name � Phone"
<br /> "Add
<br /> ress ? _ e `. L �r .,fCity.
<br /> ,Contra 's !lame ' Licensegf;?d4/
<br /> ctorPhone}
<br /> I5'CERTIFICAT£'OF WORK11ANIS COMPENSATION IHSURA"•I OII FILE'WLTN SJLFID? E�
<br /> TYPCOF WORK '(Check) NEW WELL DEEPEN❑ RECONDITION [J DESTRUCTIONd
<br /> WELL CHLOR NATION Q WELL ABANDONMENT C] . ..OTHER 0
<br /> - PUMP INSTALLATION G1 .PUMP,REPAIR 0 -.. PUMP,.REPLACEMENT p
<br /> DISTANCI+ 70 NEAREST SEPTIC TANK 1 SEWER LINES,'�p�'PIT
<br /> PRIVY
<br /> .
<br /> SEWAGE DiSP s L IELD r CESSPOOL`/SEEPAG�F;PIM,
<br /> -----=.OTHER
<br /> -PROPERTY LI TLE DOMES`fIC WELL UBLTFWE5TIt1 ��--
<br /> ,_. 44NTENDEp ytt TYPE OF WELL :CONSTRUCTION SPE IFICATI 5 f
<br /> ��z '�;In ustr, a a e Tool � Dia of a xcavat orrF �.
<br /> -„. w'ntic/private' �bri11ed; Dia af<Well=Cising ti* Ii
<br /> doines`tic'/public Driven Gauge,1of:Casingi �'f
<br /> I°rri,gation = Gravel Pack Depthiof-Groat_
<br /> fir .f .Cathodic Protection Rotary: Typerout' <
<br /> , Other ' "'Other l Ifi 6rifat o"..,
<br /> Disposal
<br /> r Geophysical 'Surface'Sea1:'T !,stalldd,--yz. dr
<br /> -
<br /> �.: ,
<br /> PUMP INSTALl:ATIilN contractor A,
<br /> Type of Pump ,h {� lr.
<br /> y,
<br /> Pl1MPR£PLACEMENT ©State work Done : r °A�
<br /> PUMP' REPAIR n� ©State.work Dome r
<br /> is+
<br /> DESTRUCTION OF WELL We11 Dirmeter
<br /> .,,fi ' � Approximate .Depth..
<br /> Describe Material an rote ure �^ ` ' Y �^° 1.
<br /> � . ,✓ .: � ray �
<br /> sThereby �certi.fy):that I have'prepared this application-and that the rrork.;will be donein atco an
<br /> with San loaquin,.County:;Ordinances, State laws, and. Rules.and:Reguiat ions:of the�5an'��oaquft� C�oct�l
<br /> Flea?th�Distri.ct Home owner or licensed agent's:signature;certifies the-:.foliowl
<br /> ng--
<br /> 4= I'certify tn�t.person,inlsuch
<br /> ,An the performance of the work�1or which this..permit is-4issued; I all
<br /> 'not',employ manner as to become subject to,Workman'.s Compensation
<br /> lawsof California. ; ; °wF ,
<br /> Ii'.fljILL.CAL ::: RrA�GR E PRIOR TO GROUTING_AND A;FINAL INSPECTION
<br /> SIGNFD s_ TITLE: as DATEa � ;>
<br /> -
<br /> ON REV SFVK Ur.
<br /> 3'HP.SE I '. - -.
<br /> `VP��T, ACCEPTED .B
<br /> - T. 1A✓ DATE-
<br /> ION
<br /> ADD IT10MAL COW.ENTS; � � � ,� Avr,No
<br /> -PHASE II GROUT INSPECTION PHASE III FINAL INSPECT103i,
<br /> INSPECTION BY DATE INSPECTION BY_( DATE,? .
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<br /> .i'Y �'al. L' •uge� F �•5 � ! . dam.'
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