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JSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£�;•OFFIC� USE: - .. <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 t <br /> APPLICATION FOR WELL CONSTRUCTION OR- PUMP <br /> , PERMIT <br /> Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ' In Tr Date Issued 2- 7 <br /> Application is hereby made to the Sano gain eLo Local Health District fora � <br /> and'/or install the work herein described. This a permit to construct <br /> County Ordinance No. 1862 and the R s $ ppZlcation is made in compliance with San Joaquii <br /> Regulations of the S oaquin Local Health District. <br /> JOB ADDRESS/LOCA N . <br /> CENSUS TRACT <br /> Owner's Name / rJ <br /> Phone - <br /> Address <br /> y ;tj <br /> G Contractor's Name ��/ 1J x citl a <br /> License 6 3phone 149 <br /> TYPE OF WORK (Check) : NEW WELL _ <br /> I DEEPEN • -7 RECONDITION /?� DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR -7 PUMP REPLACEMENT <br /> Other /% h] <br />'DISTANCE ]7(): y <br /> FOREST: SEPTIC TANK SEWER -NESJ SEWAGE DISPOSAL FIELD PIT PRIVY _ <br /> PitOPERTY LINE.: PRIVATE DOMESTIC CESSPOOL/SEEPAGE PZT OTHER <br /> INTENDED USE TYPE OF WELL MESTIC WELL PUBLIC DOMESTIC WELLi� <br /> Industrial CONSTRUCTION SPECIFI <br /> Dams tic/private -:�._ Cable Tool, Dia. of Well Excavation NS <br /> Domestic , J Drilled ' Dia. of Well Casing <br /> ---- /public Driven <br /> Irrigation •`- Gauge of Casing <br /> ravel Pack, Depth of Grout Sea <br /> Cathodic Protection <br /> l <br /> _____,Gravel <br /> _Disposal _ Other Type of Grout * . ;5,____,_Geophysical Other Information <br /> Surface Seal Installed B <br /> PUMP INSTALLATION:' _ a <br /> Contractor. � <br /> Type. of Pomp <br /> PUMP REPLACEMENT H.P� <br /> /. / S tate Work Done <br /> '.REPAIR: / ./ State Work Done <br /> DESTRUCTION OF WELL <br /> Well Diameter r <br /> scribe Ma ial d P �dur ppro pate Depth <br /> �. . <br /> I hereby agree -to comply, with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining" to. or,regulating well"" Sa tructuin <br /> after completion of my work on a new. well, I will furnish the San Joaquin Local hHealth District a �! <br /> WELL DRILLERS REPORT of the well and notif them <br /> Cnfor�nation is true Y before putting. the .well. in.use.... The above <br /> to the:best .of.. my. knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AND AFINAL INSPECTION'., ,� <br /> iIGNED <br /> (DRAW PLOT..PLAON R VVERSET <br /> LE <br /> NSxDE �� <br />'HASE I FOR DEPARTME T- USE ONLY ; ;• ,.,• <br /> SPP CATION' ACCEPTED BY !� •_; �" <br /> DDITIONAL COMMENTS., : , DATE . <br /> PHASE II GROUT INSPECT;ON <br /> NSPECTION BY � DATE P '�I I INSPECTIQN <br /> l INSPECTION BY �, •DATE . " <br /> E H 1426 Rev. 1-7 4 � �r ;f <br /> r <br />