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�= SAN JOAQUINxLOCAL--1.HEALTH DISTRICT Permit No.�7�-/3/3� <br /> FO FFICE USE: tockton5 CA 95205 <br /> i60I E. Hazelton �- <br /> Tel ephone i• (�20g) 466 5.781 Date Issued <br /> APPLICATION FOR WELL -CONSTRUCTION OR PUMP PERMIT <br /> This ,Permit :Ex ires,.l,.Year .F,ram Date•:Issued.. , <br /> Com fete In Triplicate <br /> Application is hereby made to the San Joaquin L-ocal,: HeaTtil Di•str.i de : nrcompl i ancetwithnSanuct , <br /> and/or install the work herein described: This apd- ReguTat-io ma <br /> Joaquin Count Ordinance�Not-= 1862 and the-dRules and Regulations of the .San= Joaquin Local Health <br /> y <br /> District. F � <br /> r .. CITF. <br /> Y/TOWN <br /> E EXACT STREET ADDRESS Phone % U_ / � — r <br /> Owner's Name City ' <br /> Address .. _ n. <br /> YLicense# Phone <br /> Contractor's Name ' 0 <br /> IS" CERTFFICATE OF WORKMAN'S 'COIMPENSATION IN URA'! ON -FILE' G1I.TH SJLHD? YES ' <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ® DESTRUCTION _ <br /> 1 WELL CHLM NATION 0 WELL ABANDONMENT SMP REPLAOTHERCEMENT ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR® PUMP oC <br /> _ 0 <br /> ' <br /> ` DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINESPIT PRIVY <br /> -# CESPIT OTHER_^_____r <br /> SEWAGE DISPOSAL FIELD OL/SE£PAG <br /> PROPERTY LIN VZVjPRIVA E DO FSTIC WELL 3o{PUBLIC UOMESTICwWELL Z -� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION -SPE-CIFICATIONS <br /> Industrial _� Cable Tool Dia. of Well Excavation`' <br /> Y �--Domestic/private Drilled , Dia. of Well Casing <br /> —Domestic/public Driven Gauge#of Ca,s•ing <br /> Gravel Pack Depth <br /> lo <br /> f Grot[t°'.Sea _ <br /> Irrigation T e of kraut <br /> Cathodic Protection Rotary', , . yh <br /> Disposal Other 'Other }In`format�on ` <br /> Surface Seal Install <br /> Geophysical 4, <br /> PUMP INSTALLATION: Contractor , H,p, <br /> Type 4of Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> { Approximate Depth <br /> r. DESTRUCTION OF WELL: Describem Materia an Proce ure eter r' w <br /> I hereby certify that I have prepared this application and that the work will be done in accordan <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> "I certify that in the performance oasetaobecome subjectfor which hto Workmanis permit 1s Compensationall <br /> not employ any person In such manner <br /> laws of California." <br /> I WILL CAL R A GR I PE PRIOR TO GROUTING AND A FINAL INSPECTION. DAT£. <br /> SIGNED TITLE: <br /> DR W PL T PL N ON REVS S IDE <br /> FOR DEP NT USE ONLY <br /> PHASE I DATE 1� <br /> APPLICATION ACCEPTED 8 <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> i PHASE II GROUT INSPECTION DATE S' 2- <br /> INSPECTION BY DATE INSPECTION BY C. 4Z <br /> 8_ 21 <br />