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d 23 <br /> SH[V JUAQU 1N LU�H�L kitHL 1 H l}i�1 Kil.� Permit No. , <br /> 1601 E. Hazel tori Ave.; Stockton, CA 95205 <br /> FFI,CE USE: Telephone: (209) 466-6781 Date Issued e.2-is-7 <br /> - APPLICATION FOR WELL, CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex fres 1 Year From date Issued <br /> Complete In Trip irate <br /> permit to construct <br /> rict <br /> Application is hereby made to the San Joaquin Local Ncationealth Distmade inrcompliance, with San Health <br /> and/.or :install the work herein described. This app <br /> Ordinance No. 1862 and the Rules and Regulations of the San Joaquln,Loca1 e <br /> oaquin County Ord tl <br /> District. CITY/TOWN <br /> EXACT STREET ADDRESS Phone <br /> owner'sName City � _ . <br /> Address '� _ - License# Phone <br /> Contractor' s Name - <br /> CERTIFICATE 0 f;1 d`S CO <br /> EN NSATIO`I- I`1SURAINCE-ON-FILE'WITH-SJLHD? <br /> _?S DESTRUCTION❑ o <br /> ~ DEEPEN ❑ RECONDITION ❑ OTHER Q <br /> TYPE OF WORK (Check) WELLWCHLORRINATION ❑ WELL ABANDONMENT ❑MP REPLACEMENT ❑ a <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PU <br /> TO NEAREST: SEPTIC TANK SEWER LINEJxS1py0L/SEEPAGE PIT PRIVY ' OTHER <br /> DISTANCEl CE PSEWAGE DISP SAL ,FIELDPUBLIC O-ESTIC WELL <br /> PROPERTY LINE PRIVAT DOMESTIC WELL- �---CONS, TRUCTION SPECIFICATIONS <br /> TYPE OF WELL <br /> INTENDED USE Cabe;-,Tool Dia. ' of We11 Excavation <br /> r Industrial -- - =Drilled ' ` 1 Dia. of Well Casing <br /> Domestic/private ' Gauge of Casing <br /> Domestic/public Driven <br /> � Gravel Pack Depth of Grout Seal S , <br /> 4 IrrigationRotary . Type of .Grout <br /> Cathodic Protection ---Other Other Information <br /> Disposal ' ----- Surface Seal Installed b <br /> t _Geophysical <br /> PUM IP NSTALLATION: Contractor H.P. <br /> 1 Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Done 6 <br /> PUMP REPAIR: ❑ D <br /> State Work one <br /> ` Approximate. Depth r <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materla and Pro e ure <br /> l <br /> application and that the work will be done in accorda) <br /> I hereby certify that I have prepared this app <br /> Joaquin County Ordinances , State Laws , and Rules and Regulati_ons �of..the San Joaquin Loc+ <br /> s with San qre <br /> Health District. Home owner or licensed thenworksforawhic`hthis'ce rt {permiteis�issuedg. I shall <br /> r performance of <br /> � I certify that in the p 1 <br /> not employ any person in such manner as to become subject to Workman'-s ' <br /> laws of California." F - <br /> r• i WILL CA FOR A GROUT INSPECTION PRIOR TO GROUTING AND Alip) iFINAL: INSPECTION.ti D E: � S 19 ' , <br /> TITLE: <br /> SIGNEDQ DR W PLI'll I T PL N ON REVERS£ SIDE <br /> F R D ARTMENT USE ONLY."` <br /> PHASE I - ----- DATE <br /> APPLICATION ACCEPTED 'BY <br /> ADDITIONAL COMMENTS: `� _ _-pHA E I INAL -INSPECTION <br /> PHASE -I I :GROUT--INSQE.CTION-�-- - �_INSPE:CT;ION ..BY DATE <br /> k INSP C ION BY DATE__ F <br /> . . 78 i� <br />