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�a ISAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, CAti 95205 Leit No. - <br /> FogFFICE USE: Telephone: (209) 466-67. Issued <br /> —24/7'y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> ThisPermit Ex ires 1 Year" From Date Issued <br /> Complete In Triplicate 1 <br /> .,he San Joaquin Local Health .District for a permit to construct <br /> 4 <br /> application. is hereby made to t q <br /> and/or install - the work hereinidescrab d. RThis ules apndlicationissmade, in of c-onpJoaquinwLocaIHealth <br />'oanuin County' Qrinance ,No. 1862'an +, <br /> Gistr�ct. 0_7 -S c0�'—I` � <br /> EXACT STREET AD RESS �LL" �aCITY/TOWN <br /> Phone <br /> Owner' s Name <br /> City-� 1 .. . <br /> Address ll � <br /> Contractor's Name <br /> � g �r! Li cense# Phone <br /> j <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"1 TNI SURAINCE ON FILE WIT i SJLHD? YES ✓ NO_______J__ <br /> TYPE OF WORK (Check) : NEW WELL❑ Y DEEPEN [J RECONDITION C] DESTRUCTION❑ �_ <br /> WELL CHLORINATION 0 WELLBANDIRN❑ NT ❑ OTHERMP REPLACEMENT <br /> PUMP INSTALLATION El PUMP <br /> DISTANCE TO NEAREST: SEPTIC TANK FI�LWDER LiNECESSPOOL�SEEPAGEYPIT OTHER _ <br /> SEWAGE DISPOSAL <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE I TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ,¢.'iCsn rf-.ak Cab e7_Tool Dia. of Wel l Excavation <br /> Domestic/private Drilled Dia. of Well Casing , <br /> t Domestic public Driven - - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed b <br /> 1PUMP INSTALLATION: Contractor H.V. <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Don L <br /> tate Work Don <br /> { <br /> { PUMP REPAIR: [ - w <br /> DESTRUCTION` OF VELL': _Well"Diameter Apprbximate Depth <br /> Describe Mate 1 ali, ure <br /> that the work will be done in accorda <br /> I hereby certify that I have prepared this application and tn'c <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> "I certify that in the suchnce of manner as toork for which become subjecthis to Workman' s Compensationermit is issued, I in <br /> not employ any person � suc <br /> laws of California. <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. DATE. <br /> SIGNED I . . , TITLE: . , p <br /> • DR W PLOT :PL ON REVERS SIDE <br /> :FOR D 1PARTMENT IJSE ;ONLY <br /> PHASE I �.;� { < 1,: , :� .. DATE. lC S <br /> APPLICATION ACCEPTED ::BY i <br /> IAD,DITIONAL CO -N-T PHASE ' II FIN SPECTION <br /> PH,4S" 11:. GROUT:>TNSPECTIQN <br /> k <br /> INSPEC7I0 BY <br /> 'DATE <br /> INSPECTION BY PATE -Zm` <br />