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SWOAQUIN LOCAL, HEALTH DISTRICT Permit No. �P 5 <br /> 1601 E. hazeltw Ave. ,. Stockton,. CA 952 <br /> OR +OFFICE USE: Telephone: {?09) 466,6781 Date Issued -7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit- EXires 1 Year From Date iss,ue:d1111 <br /> r , <br /> In Tri i 1 cafe ✓ .�`�- <br /> Complete p <br /> made to the San Joaquin Local. Health Di.sari-ct de�, inrcampliancetw.ithn5anuct` <br /> pplication is hereby lication 1s ma <br /> nd/or install the work herein described. This app <br /> oanu i n County O <br /> rd i hence ^+0 1862 and the Rules and :Regul ati ons _o,f. the San Joaquin, -oGal Health ` <br /> istr�ct. FTY/TOWN - <br /> XACT STREET ADDRESS Phone Egf If <br />)wner's Name - Cii;y <br /> kddress License# Phone <br />;.ontractori s Name j <br /> COMPENSATION <br /> INSURA110E ON FILE WITH SJLHD? YES NO P <br /> IS CERTIFICATE OF WORKrIAN S DESTRUCTION[3DEEPEN CJ RECONDITIGN [� <br /> TYPE OF WORK (Check) : NEW WELL 0 WELL ABANDONMENT 0 OTHER <br /> WELL CHLORINATION 0 PUMP REPLACEMENT 0 � <br /> PUMP INSTALLATION ® PUMP REPAIR❑ <br /> c <br /> PIT PRIVY OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK�De SEWER LINES Ops OL/SEEPAGE PI� <br /> SEWAGE DISPOSA FL IELDr PUBLI DC 0 ESTIC WELL _ <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL- -- RUCTION SPECIFICATIONS 41 <br /> CO'NN <br /> yTYPE OF WELL <br /> INTENDED USE Cable Tool Dia. of Well Excavation <br /> Industrial -Drilled Dia. of Well Casing <br /> 'Domestic/private Driven Gauge of Casing <br /> Domestic/public Gravel Pack Depth -of.,Grout Seal. <br /> y Irrigation -Rotary Type of Grout <br /> Cathodic Protection � Other Information . <br /> Disposal Other___., <br /> ------ Surface Seal Installed b <br /> Geophysical �... <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: p State Work Done sT�� 7 U�� <br /> r <br /> PUMP REpAiR OPe ate Work Don <br /> lives L L_ Approx matt De'NOFWELL: Weameter <br /> DESTRUCTION t <br /> Describe Materia an Proce ure <br /> this application and that the work swa#1 the donSanein JoaquinoLoca4 <br /> I hereby certify that I have prepared <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulation <br /> Health District. Home owner or licensed agent' s sig rawhichturcthisfpermiteisoissued, I shall <br /> "I certify that all <br /> in the performance of the w <br /> not em loy any person .n such manner as to.become subject to Workman's Co <br /> P <br /> laws of Cal.ifornia." <br /> I WILL CALL FO G T INSPECTiO PRIOR TO RO TING AND A FINAL I�r TI . <br /> DATE: <br /> TLE: <br /> SIGNED A L N EVER I JE _ <br /> F0 DEP RTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY ! <br /> ADDITIONAL COMMENTS: PHASE III F NAL I ACTION`� <br /> PHASE II GROUT INSPECTION `INSPECTION BY <br /> INSPECTION BY ©ATE .. <br /> � r- n <br />