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Page 34 of 51 <br /> F _ . <br /> SAN JHaZelt LOCAL Stockton, ic <br /> Cal <br /> OE�OP£IICE USE: Y lfigl P. Ilaxel tan Ave., Stockton, Calif. <br /> Telephone: (209) 444-4781 <br /> APPLICATLO.M FOR WELL CONS eRCCPION OR PUMP PER.`IIT Permit No. <br /> I <br /> TRIS PERMIT M: LRES I YEAR FROM DATE ISSUED Date issued <br /> (Complete In :rip ALcate) <br /> .,pllcetLoo iu hereby wade coithe San Joaquin iocsl Health District for a permit to conscrucc <br /> :nd/or inuta Lk the work herein described. Thio application is code in compliance with San Joaquin <br /> /arty Ordioanco No. 18gp42 and icha Rule1Aand 9egulationa of the .ioaquin Local Health DUTricz? <br /> 3,AhDRF,SS/LOCAT N CENSUS TRACT <br /> Pune.'a Name - D ' ,� phone s 0.90 <br /> Irecs c.� ( �_ .- I ryCs-�K/L�e� t/�/ City <br /> A�•C.Q.vw _ . <br /> oncractor's Naas / Lit ens e 6e16�P�hone�®"��`�� <br /> 'E OF WOkK (Check): Nxk, WELL /7 UEEPEN /7 RECONDITloN /I DESTRUCTION �)7� <br /> PUMP INSTALLATION /—/ PUMP REPAIR ( / PU?@ REPLACEMENT Fl� <br /> Daher �/ <br /> t'ANCE TD NEARE$1': SiP FC TANK SEWEk 4INFS PIT PRIVY �1 <br /> SEWAGE DISPOSAL FIELO _ CESSPOOL/SEEPAGE' PIT OTHER <br /> PROPERTY. LINE. - P NE TJ 1%AT9'tiC NEi.i._--* PUBLIC DOMESTIC WELT. <br /> INT1MDED USE TYPE OF WELL CONS^a RDCnON SPECIFICATIONS <br /> Induerrial _ l Cable Tool Via. of we11,Excavatidn <br /> _ Domestic/privsca Orllled Dia.- of-Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout.Sbal <br /> Cathodic Protection i Rotary Type-'mf GYout <br /> Disposal I _ Ocher Other In€Dreatioo _ <br /> Geophysical Surface SeaL ��En¢¢sca] .d• <br /> )MP INSTAL LATIDN: Contractor / <br /> Type of.,Pump <br /> P REPLACEMENT: / State Work Do dars�re.r�wv ]( <br /> IMP REPAIR: I I State Work Done <br /> TRUCSIO'N OF-1WELL: - WeAI_piaibeter _ Applo.o cexe Dep eh <br /> -- - - - Deecribe Muter#al and Procedure <br /> hereby agree to comply 'with all laws and regulations of thu San Joaquin Local Heolth District <br /> tho State of California partainiwg to or regulating well corstrueLLon. Within FIFTEBN DAYS 4 <br /> at coaPlction of my work on a new well, I will furnish the San Joaquin Local Stealth District a <br /> L DRILLERS REPORT of the veil and notify Chemo hefore putting the wall in use. The above <br /> :formation Is troa to the best of my knowladge and belief. F WILL•CA[.I FOR A GROUT ISSPRCTION <br /> TOR TO GROUTING AMD FIN:L MPECr LUN. <br /> IED J TITLE <br /> Jam—(DRAW PLOP KLAN 09 REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> SASE E //jj <br /> 3LICATION ACCEPT: kY I� <br /> ETE � DATE � �7� <br /> ONAL COH}}RNTS: G <br /> PRASE lI GROUT INSPECT_ ON PHASE I FIN NSPECPION f/ <br /> :OfEC'LION BY DATE INSPECYSON RY ATE ry IPJ J <br /> L R 1C2G kava 1-76 <br /> )/2011 <br />