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Page 32 of 51 <br /> r~r:1rCX <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT permit N0. <br /> OR OFFICE USE: 1601 E. Hazelton Ave.. Stockton, CA 45205 <br /> I Telephone: (20 466-6781 Date €ssued�//. <br /> APPLICATION FOR WELL.CONSTRUNSTRU CT(ON OR PUMP P£.RliIT <br /> This Permit Ex ices 1 Year From Date Issued <br /> I omp ete Tk r p fee" - <br /> Appilcati0n is hereby made to'the San Joaquin Local Health District for a permit to construct <br /> and/or install the-%101k herairi described. This application is made in compliance with San I <br /> iaquin County Ordinance No. 1a62 and the Rules and Regulations Of the Sart Joaquin Local Health <br /> Strict. II__ f [�, <br /> ErACT-STREET ADDRESS - Z'33 & 5 rraow C"`- ESTY/TOIIH <br /> .�mer's Hane� �n +`-a r•S Phone �03 <br /> (dress < - City�_-�� <br /> �untrac tort Nano: C -- License# Phone 1 ' <br /> CFRT1 EtCATC Of HORl01AIi 5 LO'flEN5ATt 0't I'75U RA'iCE ON FILE 41ITi1 SJLHD? YES N1,�.1� <br /> IPE OF WOR%1�Lheckl: NEW HELL O OEE PEN'p RECOHOITION❑ DESTRUCT ION© h}l <br /> i i 6'ELL CHLORINATION N WELL ABANDONMENT© OTHER E`3 <br /> ` PUMP 3NSTALLATION E3 RUMP REPAIR❑ PUMA REPLACEMENTS <br /> t <br /> [STAdCE T6 NEAREST: SEPTtC TAN% SEA'ER L1NE5. PIT PRIVY �' <br /> SEWAGE 01 SPUS�IELD CE 65L;SE EPAGE F1� OTHER <br /> PROPERTY LINE - PR14AT'�bESTSC WELL PUfiL C D TI <br /> 47ECL <br /> _ INTENDED USE TYPE_ OF WELL CONSTRUCT IDII SPECIFICATIONS <br /> Indus-' 1— a�0'Te`lcol Dia. of We caval on <br /> Domestic/private �Drf 11 ed Dia. of Well Casing <br /> Domestic/public =Driven Gauge of Casing <br /> _Irrigation —Gravel Pack Depth of Grout ;eal•s- <br /> Cathodic Protection Rotary Type of Grout <br /> —bisposal ` ther - _ _ . _ Dther lnformat OOn - <br /> _ Geophysical ' Surfice'Seal Instaa <br /> PLrP INSTALLATION: Contractor �- I <br /> - Type of Pump _ ingN. . <br /> UMP REPLACEMENT: 71 state Work Done _ <br /> .UNP REPAIR: Ostate Work Dane _ <br /> DESTRUCTION OF WELL: Well Diameter <br /> (.I prozi to Depth <br /> Describe Mater a an i rote ure <br /> I hereby certify that I have prepared this application and that.the work will be done in accordant <br /> with San Joaquin County Or88nances. State Laws: and Rules andi.Regulations of the San Joaquin Local <br /> yealth District. Home owner or li'cen`sed-agent'Y signature certifies the following: <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_ sublett to Workman's Compensation <br /> laws of Cali'forili'a_- <br /> I WILL CALL FOR A GR 1 SPECTIO` PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> 3GNED '. rTITLE: <br /> DATE: S 7$ <br /> OH REY <br /> DEPARTMENT U5L UqLW <br /> PHASE I s �. D,AYE <br /> -'.F LT�A71ON ACCEPTED BY <br /> ADDITIONAL CONMENTS: _ <br /> PHASE I GR U NKFMC PHASE 11yrINAl. INSPECTION <br /> 14SPECTION BY DATE INSPECTION BY DATE 9 18��ff <br /> ; .�. 1178 <br /> V2011 <br />