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SAN JOAQIifiN LOCAL HEALTH Stockton, CA <br /> permit No.,l <br /> FFICE USE: . 1601 E. Hazelton Ave. , <br /> Telephone: (209) 466-6781 Date Issued �21 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> '(Complete .Ih Triplicate)- x <br /> w, permit td Construct <br /> Application is hereby made to', the San Joaquin ,Loca1 Heation-istmade-in rcomliance with San, <br />. pp 1 i ca <br />.and/or install the work herein:.described. This app <br />� <br /> a uin Count .Regulations of the San Joaquin Local Health <br />.Jo � # <br /> q Y Ordinance No. 1862 and the Rules and <br /> District. CITY/TOWN ' .Q c <br />'EXACT'STREET ADDRESS' S � ` <br /> Phone G 2'Owner's Name AL I&U C-i ty <br /> Address .-, <br /> Li cense Phone <br /> :Contractor's Name �1 <br /> RTIFICATE OF WOP1,V, AN'S ,CO0IMPENSATI�ON IPISURA* EON FILE`WITH SJLHD? YES 0 <br /> IS CE �a .. .�.. -------- <br /> ION <br /> i <br /> DESTRUCTION " <br /> CONDIT <br /> TYPE OF WORK�(Chck) : NEW WELL OTHER WELLEN OTHER 0 <br /> WELL C _ . <br /> PUMP INSTALLATION 0 PUMP REPAIR O PUMP REPLACEMENT C7 <br /> E <br /> bISTANCE.TO NEAREST: SEPTIC TANK SEWER LINECES' S 00�/SEEPAGEYPI OTHERS <br /> SEWAGE DISP S L� FIELD WELL � PUBLiC DOMESTIC WELL <br /> { " PROPERTY LINE¢ RIVATE DOMESTIC <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Cable Tool Dia. of We Excavation f <br /> Industrial `t <br /> I �Domestic/private frilled Dia. of.: Wel1 Casing <br /> Domestic/public Driven ,, -.Dia. <br /> of Casing <br /> . - Gravel Pack Depth of Grout Sea ---w <br /> lIrrigation Type of. Grout <br /> Cathodic Protection , Rotary Other Information �. <br /> Disposal Other. <br /> Geophysical <br /> Surface Seal Insta ed b <br /> iPUMP INSTALLATION: Contractor-- r. <br /> Type1of Pump H. <br /> IPUMP REPLACEMENT: I]State Work Done- <br /> 1 PUMPyREPAIR: ❑State Work Done---- <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Materia an race ure <br /> 11 hereby. certify that I have prepared this application and that the work will be done in accor0an+ <br /> y State tawsand Rules and Regulations of the•San Joaquin ,Loca' <br /> ,With San Joaquin County Ordinances, s signature certifies the following: <br /> , <br /> �,Heal�th District: Nome owner or licensed agent' <br /> I certify that' in the performance of the work for which this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation + <br /> laws of California. <br /> fI. WILL. CALL FOR G 'T ECTION PRIOR TO GROUTING AND A- FINAL INSPECTION. DATE. S <br /> SIGN TITLE: x� <br /> IP ON REVERSESIDE <br /> f R D ARTMENT USE:PHASE I J DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: V PHASE III FINAL INSPECTION <br /> ' PHASE II GROUTrINSPECTION DATE 141 <br /> INSPECTION BY DATE INSPECTION BY 9/7 2 <br /> CLJ v n Or you Q/7R <br />